Provider Demographics
NPI:1972362705
Name:INGRAM, LEON ALAN
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:ALAN
Last Name:INGRAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 MARSHALL RD APT 24
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-5757
Mailing Address - Country:US
Mailing Address - Phone:707-439-6930
Mailing Address - Fax:
Practice Address - Street 1:1695 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4255
Practice Address - Country:US
Practice Address - Phone:707-251-1241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker