Provider Demographics
NPI:1154595676
Name:INGRAM, STEPHANIE (CSA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 FLAT SHOALS RD SE STE C238
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-6633
Mailing Address - Country:US
Mailing Address - Phone:770-354-6940
Mailing Address - Fax:
Practice Address - Street 1:863 FLAT SHOALS RD SE STE C238
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6633
Practice Address - Country:US
Practice Address - Phone:770-354-6940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3135363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical