Provider Demographics
NPI:1972132066
Name:INGRAM, THERESSA (LVN)
Entity type:Individual
Prefix:
First Name:THERESSA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4852 J R CT
Mailing Address - Street 2:
Mailing Address - City:ROYSE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75189-8109
Mailing Address - Country:US
Mailing Address - Phone:575-200-8382
Mailing Address - Fax:
Practice Address - Street 1:4852 J R CT
Practice Address - Street 2:
Practice Address - City:ROYSE CITY
Practice Address - State:TX
Practice Address - Zip Code:75189-8109
Practice Address - Country:US
Practice Address - Phone:575-200-8382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX349904164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse