Provider Demographics
NPI:1831711498
Name:INGRAM, EVETTE RENEE
Entity type:Individual
Prefix:
First Name:EVETTE
Middle Name:RENEE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1581 E COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2132
Mailing Address - Country:US
Mailing Address - Phone:818-220-4563
Mailing Address - Fax:
Practice Address - Street 1:1581 E COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2132
Practice Address - Country:US
Practice Address - Phone:626-639-3077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-17
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies