Provider Demographics
NPI:1285179796
Name:INGRAM, SAMANTHA (BAE)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:BAE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 AUBURN BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-2005
Mailing Address - Country:US
Mailing Address - Phone:916-482-2370
Mailing Address - Fax:916-349-7537
Practice Address - Street 1:3555 AUBURN BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-2005
Practice Address - Country:US
Practice Address - Phone:916-482-2370
Practice Address - Fax:916-349-7537
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator