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General NPI Number Information
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NPI Number | 1003328667
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Entity Type | Individual
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Provider Name | PHYLLIS ANNETTE INGHAM NP-C
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Gender | Female
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Dates
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Enumeration Date | 11/03/2017
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Last Update Date | 12/02/2025
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Provider Practice Location Address
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Address Line | 750 N BROADWAY
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City | PERU
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State | IN
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Zip | 46970-1027
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Country | US
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Telephone | 260-569-2120
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Fax | 260-569-2121
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Provider Business Mailing Address
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Address Line | 11109 PARKVIEW PLAZA DR # 117
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City | FORT WAYNE
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State | IN
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Zip | 46845-1701
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 71009335A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | AP134764
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | CNP-03521
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License Number State | NM
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