Provider Demographics
NPI:1518559566
Name:INGRAM, MARY BROOKS (RN, LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BROOKS
Last Name:INGRAM
Suffix:
Gender:F
Credentials:RN, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10301 GRAND CENTRAL AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4067
Mailing Address - Country:US
Mailing Address - Phone:410-905-9659
Mailing Address - Fax:
Practice Address - Street 1:10301 GRAND CENTRAL AVE APT 205
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4067
Practice Address - Country:US
Practice Address - Phone:410-905-9659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR200895163W00000X
MDU02794171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR200895OtherMARYLAND BOARD OF NURSING
MDU02794OtherMARYLAND BOARD OF ACUPUNCTURE