Healthcare Provider Details

I. General information

NPI: 1497250559
Provider Name (Legal Business Name): INGRAM'S NUTRITION CONSULTATIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 E GREGG ST
SHREVEPORT LA
71104-5158
US

IV. Provider business mailing address

219 E GREGG ST
SHREVEPORT LA
71104-5158
US

V. Phone/Fax

Practice location:
  • Phone: 318-572-6157
  • Fax: 800-708-7349
Mailing address:
  • Phone: 318-572-6157
  • Fax: 800-708-7349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JULIETTE SHIVERS
Title or Position: CEO/COMMUNITY NUTRITION
Credential: NP
Phone: 318-572-6157