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General NPI Number Information
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NPI Number | 1427693126
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Entity Type | Individual
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Provider Name | SUSAN RENAE INGRAM LPTA
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Gender | Female
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Dates
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Enumeration Date | 11/17/2019
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Last Update Date | 11/21/2019
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Provider Practice Location Address
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Address Line | 911 STACEY BURK DR
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City | FLORA
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State | IL
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Zip | 62839-3241
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Country | US
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Telephone | 618-292-4655
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Fax |
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Provider Business Mailing Address
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Address Line | 392 GOSHAWK LN
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City | FARINA
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State | IL
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Zip | 62838-3734
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Country | US
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Telephone | 618-292-4655
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 160-003878
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License Number State | IL
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