Healthcare Provider Details

I. General information

NPI: 1174012249
Provider Name (Legal Business Name): TANIAH INGRAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1732 BENJAMIN AVE NE
GRAND RAPIDS MI
49505-5434
US

IV. Provider business mailing address

1732 BENJAMIN AVE NE
GRAND RAPIDS MI
49505-5434
US

V. Phone/Fax

Practice location:
  • Phone: 616-914-0795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: