Provider Demographics
NPI:1396326302
Name:INGHAM, MARY KAY (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:INGHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 YALE BLVD SE STE A3
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4350
Mailing Address - Country:US
Mailing Address - Phone:505-385-8028
Mailing Address - Fax:855-254-6287
Practice Address - Street 1:2301 YALE BLVD SE STE A3
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4350
Practice Address - Country:US
Practice Address - Phone:505-385-8028
Practice Address - Fax:855-254-6287
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT3342251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics