Healthcare Provider Details

I. General information

NPI: 1396551776
Provider Name (Legal Business Name): KARAE-MIYANI D INGRAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 ROBIN HOOD RD STE 126
NORFOLK VA
23513-2419
US

IV. Provider business mailing address

1640 E PARHAM RD
RICHMOND VA
23228-2368
US

V. Phone/Fax

Practice location:
  • Phone: 855-444-9838
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: