Provider Demographics
NPI:1316117997
Name:INGRAM, CORINNE ANGELIQUE FRANCES (DPT)
Entity type:Individual
Prefix:MRS
First Name:CORINNE
Middle Name:ANGELIQUE FRANCES
Last Name:INGRAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:CORINNE
Other - Middle Name:ANGELIQUE FRANCES
Other - Last Name:KISTKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1675 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1110
Mailing Address - Country:US
Mailing Address - Phone:847-723-4532
Mailing Address - Fax:
Practice Address - Street 1:1675 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1110
Practice Address - Country:US
Practice Address - Phone:847-723-4532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist