Basic Information
| Provider Information | |||||||||
| NPI: | 1306176805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | INGRAM | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEWIS | ||||||||
| OtherFirstName: | ALICIA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 MALLARD CREEK RD | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026908782 | ||||||||
| FaxNumber: | 5024590923 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MALLARD CREEK RD | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026908782 | ||||||||
| FaxNumber: | 5024590923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2010 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1106765 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 48489 | 01 | KY | CRNA | OTHER | RN335792 | 01 | OH | OHIO RN LICENSE | OTHER |