Healthcare Provider Details

I. General information

NPI: 1396326302
Provider Name (Legal Business Name): MARY KAY INGHAM PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 YALE BLVD SE STE A3
ALBUQUERQUE NM
87106-4350
US

IV. Provider business mailing address

2301 YALE BLVD SE STE A3
ALBUQUERQUE NM
87106-4350
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-8028
  • Fax: 855-254-6287
Mailing address:
  • Phone: 505-385-8028
  • Fax: 855-254-6287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT334
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: