Healthcare Provider Details

I. General information

NPI: 1124939319
Provider Name (Legal Business Name): NANCI E INGRAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 LIVINGSTON ST
CALDWELL ID
83607-1026
US

IV. Provider business mailing address

1405 LIVINGSTON ST
CALDWELL ID
83607-1026
US

V. Phone/Fax

Practice location:
  • Phone: 986-210-7177
  • Fax:
Mailing address:
  • Phone: 986-210-7177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number54925
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: