Provider Demographics
NPI:1942564711
Name:INGRAM, LILLIAN
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:INGRAM
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 1:1211 TECH BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-7846
Mailing Address - Country:US
Mailing Address - Phone:813-999-1516
Mailing Address - Fax:813-336-8384
Practice Address - Street 1:1211 TECH BLVD STE 105
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-7846
Practice Address - Country:US
Practice Address - Phone:813-999-1516
Practice Address - Fax:813-336-8384
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9359459363LF0000X, 363LP0808X
GARN223698363LF0000X
RIAPRN02951363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102546400Medicaid
FL$$$$$$$$$OtherSS