Provider Demographics
NPI:1033283817
Name:INGRUM, TARA LYNN (LMP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYNN
Last Name:INGRUM
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:318 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273
Mailing Address - Country:US
Mailing Address - Phone:360-336-2794
Mailing Address - Fax:360-336-1921
Practice Address - Street 1:422 N 4TH ST SUITE 104
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-336-2794
Practice Address - Fax:360-336-1921
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00008671225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist