Provider Demographics
NPI:1225490725
Name:INGRAM, LARISSA (LPN)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572 W LACLEDE AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-1742
Mailing Address - Country:US
Mailing Address - Phone:330-942-2180
Mailing Address - Fax:
Practice Address - Street 1:572 W LACLEDE AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-1742
Practice Address - Country:US
Practice Address - Phone:330-942-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN110988164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse