Provider Demographics
NPI:1801561089
Name:INGRAM, KOURTNEY (AGACNP)
Entity type:Individual
Prefix:MRS
First Name:KOURTNEY
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:KOURTNEY
Other - Middle Name:ALIS
Other - Last Name:TUKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4501 RUSSELL PKWY STE 31
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8681
Mailing Address - Country:US
Mailing Address - Phone:478-273-0131
Mailing Address - Fax:
Practice Address - Street 1:306 N DAVIS DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3475
Practice Address - Country:US
Practice Address - Phone:478-273-0131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN266250363LA2200X, 363LA2100X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner