Provider Demographics
NPI:1386360436
Name:INGRAM, LATEIFAH SHAREE
Entity type:Individual
Prefix:
First Name:LATEIFAH
Middle Name:SHAREE
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 1:314 PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-8053
Mailing Address - Country:US
Mailing Address - Phone:919-440-2650
Mailing Address - Fax:
Practice Address - Street 1:110 E MAIN ST STE 200D
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-4029
Practice Address - Country:US
Practice Address - Phone:919-440-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251E00000X
NCHC6967253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC87122057OtherHOME CARE