Provider Demographics
NPI:1922045251
Name:MULLIS-INGRAM, ANGELA (NP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MULLIS-INGRAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 WASHINGTON ST FL 14
Mailing Address - Street 2:EIGHT TOWER BRIDGE
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2083
Mailing Address - Country:US
Mailing Address - Phone:866-825-3227
Mailing Address - Fax:
Practice Address - Street 1:408 E MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4542
Practice Address - Country:US
Practice Address - Phone:866-825-3227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3093102207P00000X
FL3093102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY061GYMedicare ID - Type Unspecified
FLQ26240Medicare UPIN