Provider Demographics
NPI:1336280213
Name:INGRAM-MITCHELL, KATHRYN KELLY (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:KELLY
Last Name:INGRAM-MITCHELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 CORMORANT COVE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-2777
Mailing Address - Country:US
Mailing Address - Phone:904-215-7200
Mailing Address - Fax:904-541-0616
Practice Address - Street 1:524 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4830
Practice Address - Country:US
Practice Address - Phone:904-215-7200
Practice Address - Fax:904-541-0616
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18848225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist