Provider Demographics
NPI:1154931558
Name:INGRAM, TANEA
Entity type:Individual
Prefix:
First Name:TANEA
Middle Name:
Last Name:INGRAM
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 1:1285 STRATFORD AVE # G202
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-2026
Mailing Address - Country:US
Mailing Address - Phone:707-679-0321
Mailing Address - Fax:
Practice Address - Street 1:1285 STRATFORD AVE # G202
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:CA
Practice Address - Zip Code:95620-2026
Practice Address - Country:US
Practice Address - Phone:707-679-0321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle