Provider Demographics
NPI:1932292612
Name:INGRAM, TINA MICHELLE (DC, FNP-C, DIPLAC)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:MICHELLE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:DC, FNP-C, DIPLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 W DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:TX
Mailing Address - Zip Code:75103-1009
Mailing Address - Country:US
Mailing Address - Phone:903-567-5579
Mailing Address - Fax:903-567-5938
Practice Address - Street 1:921 W DALLAS ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-1009
Practice Address - Country:US
Practice Address - Phone:903-567-5579
Practice Address - Fax:903-567-5938
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6598111N00000X
TX1012507363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87391YOtherBCBS
TX87391YOtherBCBS