Provider Demographics
NPI:1811005333
Name:INGRAM, CAROLYNE MICHELE (ARNP)
Entity Type:Individual
Prefix:
First Name:CAROLYNE
Middle Name:MICHELE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 CORNWALL AVE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-3719
Mailing Address - Country:US
Mailing Address - Phone:360-647-1900
Mailing Address - Fax:
Practice Address - Street 1:MT. SHUKSAN FAMILY MEDICINE
Practice Address - Street 2:2216 CORNWALL AVE
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225
Practice Address - Country:US
Practice Address - Phone:360-647-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003413363LX0001X
CA5834363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9613050Medicaid
8801075Medicare ID - Type Unspecified
P45061Medicare UPIN