Provider Demographics
NPI:1265817381
Name:INGRAM, BERNADETTE
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
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 1:19165 PLAINVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-2732
Mailing Address - Country:US
Mailing Address - Phone:313-806-0230
Mailing Address - Fax:
Practice Address - Street 1:19165 PLAINVIEW AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-2732
Practice Address - Country:US
Practice Address - Phone:313-806-0230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker