Healthcare Provider Details

I. General information

NPI: 1639915713
Provider Name (Legal Business Name): VICTORIA FAYTH INGRAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 W AUGUSTA BLVD STE 1
CHICAGO IL
60642-4327
US

IV. Provider business mailing address

5 BARBARA CT
SPRINGFIELD IL
62704-4949
US

V. Phone/Fax

Practice location:
  • Phone: 773-248-2255
  • Fax:
Mailing address:
  • Phone: 314-608-1280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011632
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: