Provider Demographics
NPI:1124500681
Name:INGRAM, TANA D (MS, RDN)
Entity type:Individual
Prefix:
First Name:TANA
Middle Name:D
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22072 E PECAN DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-4895
Mailing Address - Country:US
Mailing Address - Phone:480-495-0314
Mailing Address - Fax:
Practice Address - Street 1:1840 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1614
Practice Address - Country:US
Practice Address - Phone:480-495-0314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86069798133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered