Healthcare Provider Details

I. General information

NPI: 1275636268
Provider Name (Legal Business Name): LAURA INGRAM LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 LAFAYETTE ST SUITE K
MARIANNA FL
32446-3410
US

IV. Provider business mailing address

4440 LAFAYETTE ST SUITE K
MARIANNA FL
32446-3410
US

V. Phone/Fax

Practice location:
  • Phone: 850-482-0082
  • Fax: 850-482-0095
Mailing address:
  • Phone: 850-209-8388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA48057
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: