Provider Demographics
NPI:1306176805
Name:INGRAM, ALICIA ANN (CRNA)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANN
Last Name:INGRAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:ANN
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:100 MALLARD CREEK RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4194
Mailing Address - Country:US
Mailing Address - Phone:502-690-8782
Mailing Address - Fax:502-459-0923
Practice Address - Street 1:100 MALLARD CREEK RD
Practice Address - Street 2:SUITE 320
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4194
Practice Address - Country:US
Practice Address - Phone:502-690-8782
Practice Address - Fax:502-459-0923
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1106765367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY48489OtherCRNA
OHRN335792OtherOHIO RN LICENSE
IN200991930Medicaid
KY7100129890Medicaid