Provider Demographics
NPI:1205206349
Name:INGRAM FARRIS, DANIELLE (BA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:INGRAM FARRIS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:FARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:502 FARRELL DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3717
Mailing Address - Country:US
Mailing Address - Phone:859-578-3204
Mailing Address - Fax:859-578-3273
Practice Address - Street 1:513 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-1562
Practice Address - Country:US
Practice Address - Phone:859-431-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherTAX ID