Provider Demographics
NPI:1902913197
Name:INGRAM, MIRIAM W (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:W
Last Name:INGRAM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 FAIRVIEW AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216
Mailing Address - Country:US
Mailing Address - Phone:410-542-4773
Mailing Address - Fax:410-542-4773
Practice Address - Street 1:3102 N HILTON STREET
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216
Practice Address - Country:US
Practice Address - Phone:410-578-0730
Practice Address - Fax:410-578-0978
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR051001363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1292767OtherFEDERAL DEA
MI1292767OtherFEDERAL DEA