Provider Demographics
NPI:1821379272
Name:INGHAM, TRACY LYNN (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:INGHAM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:STAMBOLDJIEV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:3603 RAINBOW DR
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-1036
Mailing Address - Country:US
Mailing Address - Phone:651-895-9464
Mailing Address - Fax:
Practice Address - Street 1:424 W STATE HIGHWAY 5
Practice Address - Street 2:LAKEVIEW CLINIC LTD
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1723
Practice Address - Country:US
Practice Address - Phone:952-442-4461
Practice Address - Fax:952-442-1213
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA0611105363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health