Provider Demographics
NPI:1558184234
Name:TRACY INGRAM LLC
Entity type:Organization
Organization Name:TRACY INGRAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LARGADO
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, PMHNP-BC
Authorized Official - Phone:808-583-6411
Mailing Address - Street 1:98-1247 KAAHUMANU ST STE 106
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5310
Mailing Address - Country:US
Mailing Address - Phone:808-583-6411
Mailing Address - Fax:808-480-7589
Practice Address - Street 1:98-1247 KAAHUMANU ST STE 106
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-5310
Practice Address - Country:US
Practice Address - Phone:808-583-6411
Practice Address - Fax:808-480-7589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty