Provider Demographics
NPI:1558042804
Name:INGRAM, MARY MI'SHON (RN, NP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MI'SHON
Last Name:INGRAM
Suffix:
Gender:F
Credentials:RN, NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3510
Mailing Address - Country:US
Mailing Address - Phone:229-815-0270
Mailing Address - Fax:
Practice Address - Street 1:713 20TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8920
Practice Address - Country:US
Practice Address - Phone:706-660-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN274291363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty