Provider Demographics
NPI:1790065563
Name:INGRAM, MICHELLE LEIGH (LPN-IV)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEIGH
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LPN-IV
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LEIGH
Other - Last Name:RHINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2271 STATE ROUTE 162 E
Mailing Address - Street 2:
Mailing Address - City:NORTH FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44855-9420
Mailing Address - Country:US
Mailing Address - Phone:419-677-6930
Mailing Address - Fax:
Practice Address - Street 1:2271 STATE ROUTE 162 E
Practice Address - Street 2:
Practice Address - City:NORTH FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:44855-9420
Practice Address - Country:US
Practice Address - Phone:419-677-6930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.125799-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse