Provider Demographics
NPI:1366009128
Name:INGRAM, NYTASIA
Entity Type:Individual
Prefix:
First Name:NYTASIA
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 1:443 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34266-3741
Mailing Address - Country:US
Mailing Address - Phone:321-704-6116
Mailing Address - Fax:
Practice Address - Street 1:8359 BEACON BLVD STE 416
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3065
Practice Address - Country:US
Practice Address - Phone:407-801-9924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician