MEDICARE: LEON ALAN INGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1972362705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEON ALAN INGRAM

Provider Business Mailing Address
First Line	:	999 MARSHALL RD APT 24
Second Line	:
City	:	VACAVILLE
State	:	CA
Zip	:	95687-5757
Country	:	US
Telephone Number	:	707-439-6930
Fax Number	:

Provider Business Practice Location Address
First Line	:	1695 SUNSET AVE
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-4255
Country	:	US
Telephone Number	:	707-251-1241
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2024
Last Update Date	:	03/14/2024

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Directions to “ LEON ALAN INGRAM ” Practice Location

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