Provider Demographics
NPI:1013597491
Name:INGRAM, MIRANDA ELLEN (PTA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ELLEN
Last Name:INGRAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 WESTRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:KY
Mailing Address - Zip Code:40361-2483
Mailing Address - Country:US
Mailing Address - Phone:859-435-5325
Mailing Address - Fax:
Practice Address - Street 1:2117 ROCKY DR
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:KY
Practice Address - Zip Code:40361-1370
Practice Address - Country:US
Practice Address - Phone:859-988-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-10
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA04124225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant