Basic Information
| Provider Information | |||||||||
| NPI: | 1003892845 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | INGRAM | ||||||||
| FirstName: | JOANNE | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24630 WASHINGTON AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925626177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516969353 | ||||||||
| FaxNumber: | 9519737216 | ||||||||
| Practice Location | |||||||||
| Address1: | 17270 BEAR VALLEY RD | ||||||||
| Address2: | STE E-105 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923957751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609556061 | ||||||||
| FaxNumber: | 7609556062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 01/07/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT13147 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0PT131472 | 01 | CA | MEDICARE PTAN | OTHER | 0219113 | 01 | WA | STATE OF WA | OTHER |