Provider Demographics
NPI:1700442373
Name:INGRAM, WENDY ANN (COTA)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:ANN
Last Name:INGRAM
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3128 SIR HAMILTON CIR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-4962
Mailing Address - Country:US
Mailing Address - Phone:407-233-5244
Mailing Address - Fax:
Practice Address - Street 1:1705 JESS PARRISH CT
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2158
Practice Address - Country:US
Practice Address - Phone:321-269-5720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-19
Last Update Date:2019-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13989224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant