1568758407 NPI number — CASSANDRA LEE INGRAM M.S., LPE-I

Table of content: CASSANDRA LEE INGRAM M.S., LPE-I (NPI 1568758407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568758407 NPI number — CASSANDRA LEE INGRAM M.S., LPE-I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INGRAM
Provider First Name:
CASSANDRA
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., LPE-I
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568758407
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 414
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENBRIER
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72058-0414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-679-0232
Provider Business Mailing Address Fax Number:
833-373-0348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 S BROADVIEW ST STE EANDF
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENBRIER
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72058-9601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-679-0232
Provider Business Practice Location Address Fax Number:
833-373-0348
Provider Enumeration Date:
06/20/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: 13-14EI , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)