Provider Demographics
NPI:1659038040
Name:INGRAM, TRACY LARGADO
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LARGADO
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:PO BOX 893871
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-0871
Mailing Address - Country:US
Mailing Address - Phone:808-391-5225
Mailing Address - Fax:
Practice Address - Street 1:98-1247 KAAHUMANU ST STE 106
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-5310
Practice Address - Country:US
Practice Address - Phone:808-391-5225
Practice Address - Fax:808-888-2817
Is Sole Proprietor?:No
Enumeration Date:2021-11-20
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-45413163WP0808X
HIAPRN-3566363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health