Provider Demographics
NPI:1366862344
Name:INGRAM, SUSANNE
Entity Type:Individual
Prefix:
First Name:SUSANNE
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 1:309 KERSHAW ST
Mailing Address - Street 2:
Mailing Address - City:CHERAW
Mailing Address - State:SC
Mailing Address - Zip Code:29520-2606
Mailing Address - Country:US
Mailing Address - Phone:843-537-5946
Mailing Address - Fax:843-623-3066
Practice Address - Street 1:203 NORTH PAGE STREET
Practice Address - Street 2:CHESTERFIELD COUNTY HEALTH DEPT.
Practice Address - City:CHESTERFIELD
Practice Address - State:SC
Practice Address - Zip Code:29709
Practice Address - Country:US
Practice Address - Phone:843-623-2117
Practice Address - Fax:843-623-3066
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25736163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse