Provider Demographics
NPI:1083208037
Name:INGRAM, CARRIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ELIZABETH
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 1:110 N 4TH ST.
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1536
Mailing Address - Country:US
Mailing Address - Phone:580-749-5056
Mailing Address - Fax:580-215-5765
Practice Address - Street 1:110 N 4TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4527
Practice Address - Country:US
Practice Address - Phone:580-749-5056
Practice Address - Fax:580-215-5762
Is Sole Proprietor?:No
Enumeration Date:2021-02-21
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator