Basic Information
| Provider Information | |||||||||
| NPI: | 1386025880 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INGRAM | ||||||||
| FirstName: | TERESA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 CHESTNUT ST | ||||||||
| Address2: | 4E | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191034522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106133784 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 E TOWNSHIP LINE RD | ||||||||
| Address2: | |||||||||
| City: | HAVERTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190835733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889852727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2015 | ||||||||
| LastUpdateDate: | 05/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP014998 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.