Provider Demographics
NPI:1578146171
Name:LILLIAN INGRAM
Entity Type:Organization
Organization Name:LILLIAN INGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:608-217-6108
Mailing Address - Street 1:1211 TECH BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-7846
Mailing Address - Country:US
Mailing Address - Phone:813-999-1516
Mailing Address - Fax:813-336-8384
Practice Address - Street 1:1211 TECH BLVD STE 105
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-7846
Practice Address - Country:US
Practice Address - Phone:813-999-1516
Practice Address - Fax:813-336-8384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-30
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty