Provider Demographics
NPI:1295726859
Name:INGRUM, LAURA MICHELLE (NP-C)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MICHELLE
Last Name:INGRUM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:M/MED/QI, SA-1
Mailing Address - Street 2:US DEPARTMENT OF STATE
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20522-0102
Mailing Address - Country:US
Mailing Address - Phone:202-663-1519
Mailing Address - Fax:260-496-8077
Practice Address - Street 1:M/MED/QI, SA-1
Practice Address - Street 2:US DEPARTMENT OF STATE
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20522-0102
Practice Address - Country:US
Practice Address - Phone:202-663-1519
Practice Address - Fax:260-496-8077
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM14704261482363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71001999AOtherNP LICENSE