Healthcare Provider Details

I. General information

NPI: 1154839462
Provider Name (Legal Business Name): NADYRA INGRAM ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2018
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

PO BOX 2400
MELBOURNE FL
32902-2400
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-7000
  • Fax:
Mailing address:
  • Phone: 321-837-3820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP949036
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: