Provider Demographics
NPI:1275636268
Name:INGRAM, LAURA (LMT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 LAFAYETTE ST
Mailing Address - Street 2:SUITE K
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-3410
Mailing Address - Country:US
Mailing Address - Phone:850-209-8388
Mailing Address - Fax:
Practice Address - Street 1:4440 LAFAYETTE ST
Practice Address - Street 2:SUITE K
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-3410
Practice Address - Country:US
Practice Address - Phone:850-482-0082
Practice Address - Fax:850-482-0095
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA48057225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist