Healthcare Provider Details

I. General information

NPI: 1295779221
Provider Name (Legal Business Name): YVETTE M INGRAM PHD, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 WILLIS HEALTH PROFESSIONS BUILDING LOCK HAVEN UNIVERSITY
LOCK HAVEN PA
17745-1212
US

IV. Provider business mailing address

115 WILLIS HEALTH PROFESSIONS BUILDING LOCK HAVEN UNIVERSITY
LOCK HAVEN PA
17745-1212
US

V. Phone/Fax

Practice location:
  • Phone: 570-660-0738
  • Fax:
Mailing address:
  • Phone: 570-660-0738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT001325A
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: