Provider Demographics
NPI:1336133099
Name:INGRAM, TRACY LEA (FNP, RN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEA
Last Name:INGRAM
Suffix:
Gender:F
Credentials:FNP, RN
Other - Prefix:MISS
Other - First Name:TRACY
Other - Middle Name:LEA
Other - Last Name:RUBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNPRN
Mailing Address - Street 1:3306 N COUNTY ROAD 420 W
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47240-7793
Mailing Address - Country:US
Mailing Address - Phone:812-663-7596
Mailing Address - Fax:
Practice Address - Street 1:718 N LINCOLN ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:IN
Practice Address - Zip Code:47240-1348
Practice Address - Country:US
Practice Address - Phone:812-662-0588
Practice Address - Fax:812-663-5932
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001970A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200537070Medicaid
IN178730TMedicare PIN
Q57308Medicare UPIN
IN200537070Medicaid