Provider Demographics
NPI:1154782225
Name:INGRAHAM, JODY MARIE
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:MARIE
Last Name:INGRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ENGLISH ST
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-2505
Mailing Address - Country:US
Mailing Address - Phone:315-985-1103
Mailing Address - Fax:
Practice Address - Street 1:11 ENGLISH ST
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-2505
Practice Address - Country:US
Practice Address - Phone:315-985-1103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide