Provider Demographics
NPI:1770856163
Name:INGRAM, LORA
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:
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 1:1054 GARDENIA RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-6002
Mailing Address - Country:US
Mailing Address - Phone:757-461-5001
Mailing Address - Fax:
Practice Address - Street 1:1054 GARDENIA RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-6002
Practice Address - Country:US
Practice Address - Phone:757-461-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001316225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant