Provider Demographics
NPI:1922748649
Name:INGRAM MOORE, DARCEL LEANN
Entity Type:Individual
Prefix:
First Name:DARCEL
Middle Name:LEANN
Last Name:INGRAM MOORE
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 1:178 ARLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1247
Mailing Address - Country:US
Mailing Address - Phone:313-918-7853
Mailing Address - Fax:
Practice Address - Street 1:178 ARLINGTON ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-1247
Practice Address - Country:US
Practice Address - Phone:313-918-7853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230015346550711251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care