Basic Information
| Provider Information | |||||||||
| NPI: | 1417521915 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INGRAM | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 ROCKDALE BLVD | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291547161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8065359999 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 E CHEVES ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295062617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437772000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2021 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | SC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 367500000X | 25215 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.