MEDICARE: TANA D INGRAM MS, RDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	86069798

General Provider Information

NPI Number	:	1124500681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANA D INGRAM MS, RDN

Provider Business Mailing Address
First Line	:	929 N VAL VISTA DRIVE, STE 109
Second Line	:	PMB 1503
City	:	GILBERT
State	:	AZ
Zip	:	85234-3701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	22072 E PECAN DR
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-4895
Country	:	US
Telephone Number	:	480-495-0314
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2018
Last Update Date	:	06/25/2026

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