Provider Demographics
NPI:1235646472
Name:INGRAM, NICKI GOSSAGE (BS, CLC, LCCE, IBCLC)
Entity Type:Individual
Prefix:
First Name:NICKI
Middle Name:GOSSAGE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:BS, CLC, LCCE, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 SOUTHVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-6234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1920 SOUTHVIEW AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-6234
Practice Address - Country:US
Practice Address - Phone:918-578-9036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty