Provider Demographics
NPI:1710519277
Name:INGRAM, SHALETA SHONTEL (CNP)
Entity Type:Individual
Prefix:MRS
First Name:SHALETA
Middle Name:SHONTEL
Last Name:INGRAM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1320 S JOHN REDDITT DR STE B
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-4368
Mailing Address - Country:US
Mailing Address - Phone:936-225-3657
Mailing Address - Fax:936-899-7293
Practice Address - Street 1:1320 S JOHN REDDITT DR STE B
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-4368
Practice Address - Country:US
Practice Address - Phone:936-225-3657
Practice Address - Fax:936-899-7293
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145110363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily