Provider Demographics
NPI:1003159682
Name:INGRAM, TAKEYRA RAEDAWN
Entity Type:Individual
Prefix:
First Name:TAKEYRA
Middle Name:RAEDAWN
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WINLEY CHASE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-1123
Mailing Address - Country:US
Mailing Address - Phone:702-619-6884
Mailing Address - Fax:
Practice Address - Street 1:205 WINLEY CHASE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-1123
Practice Address - Country:US
Practice Address - Phone:702-619-6884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner