Provider Demographics
NPI:1316246820
Name:INGRAM, ISA (LAC)
Entity type:Individual
Prefix:
First Name:ISA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:GOCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:3940 H ST APT 207
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-2759
Mailing Address - Country:US
Mailing Address - Phone:916-413-6625
Mailing Address - Fax:
Practice Address - Street 1:4150 V ST STE 1200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1460
Practice Address - Country:US
Practice Address - Phone:916-413-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2022-07-08
Deactivation Date:2019-08-14
Deactivation Code:
Reactivation Date:2021-04-07
Provider Licenses
StateLicense IDTaxonomies
CAAC 12674171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist