Provider Demographics
NPI:1619459518
Name:INGRAM, OCTAVIA (DNP, FNP-C, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:OCTAVIA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:DNP, FNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13729 TAB DR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35475-1694
Mailing Address - Country:US
Mailing Address - Phone:662-312-2258
Mailing Address - Fax:
Practice Address - Street 1:13729 TAB DR
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35475-1694
Practice Address - Country:US
Practice Address - Phone:929-949-3134
Practice Address - Fax:929-929-1476
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-142018363LF0000X
NY403475363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily