Provider Demographics
NPI:1295856730
Name:INGRAM, LIZA DANIELLE (DPT)
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:DANIELLE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MIDDLEBURG DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32413-2855
Mailing Address - Country:US
Mailing Address - Phone:239-770-1227
Mailing Address - Fax:
Practice Address - Street 1:209 MIDDLEBURG DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413-2855
Practice Address - Country:US
Practice Address - Phone:239-770-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist