Provider Demographics
NPI:1326815879
Name:INGRAM, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
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 1:435198 E 1940 RD
Mailing Address - Street 2:
Mailing Address - City:FORT TOWSON
Mailing Address - State:OK
Mailing Address - Zip Code:74735
Mailing Address - Country:US
Mailing Address - Phone:580-271-1370
Mailing Address - Fax:
Practice Address - Street 1:300 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2053
Practice Address - Country:US
Practice Address - Phone:580-830-0667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2587225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist