Provider Demographics
NPI:1366825648
Name:INGRAM, KENISHA ROSE
Entity Type:Individual
Prefix:
First Name:KENISHA
Middle Name:ROSE
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 1:3216 PAUMANOK WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-2450
Mailing Address - Country:US
Mailing Address - Phone:916-470-7404
Mailing Address - Fax:
Practice Address - Street 1:3216 PAUMANOK WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95835-2450
Practice Address - Country:US
Practice Address - Phone:916-470-7404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-03
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1022166251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health