Healthcare Provider Details

I. General information

NPI: 1881365583
Provider Name (Legal Business Name): EBONY ELISE INGRAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 17TH ST STE 2
OAKLAND CA
94612-2820
US

IV. Provider business mailing address

426 17TH ST FL 2
OAKLAND CA
94612-2820
US

V. Phone/Fax

Practice location:
  • Phone: 510-433-8600
  • Fax:
Mailing address:
  • Phone: 510-433-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: