Healthcare Provider Details

I. General information

NPI: 1659038040
Provider Name (Legal Business Name): TRACY LARGADO INGRAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2021
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98-1247 KAAHUMANU ST STE 106
AIEA HI
96701-5310
US

IV. Provider business mailing address

PO BOX 893871
MILILANI HI
96789-0871
US

V. Phone/Fax

Practice location:
  • Phone: 808-391-5225
  • Fax: 808-888-2817
Mailing address:
  • Phone: 808-391-5225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-3566
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN-45413
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: