Provider Demographics
NPI:1326241530
Name:INGRAM, LORI MARIE (COTAL)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:MARIE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:MARIE
Other - Last Name:DEZARN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTAL
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:396 SUNSET RD
Mailing Address - City:SUNSET
Mailing Address - State:ME
Mailing Address - Zip Code:04683-0005
Mailing Address - Country:US
Mailing Address - Phone:207-348-6187
Mailing Address - Fax:
Practice Address - Street 1:587 NORTH DEER ISLE RD
Practice Address - Street 2:ISLAND NURSING HOME
Practice Address - City:DEER ISLE
Practice Address - State:ME
Practice Address - Zip Code:04627
Practice Address - Country:US
Practice Address - Phone:207-348-2351
Practice Address - Fax:207-348-6154
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0A1383224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant