Individual
MRS. SUSAN RENAE INGRAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPTA
Contact information
Practice address
911 STACEY BURK DR, FLORA, IL 62839-3241
(618) 292-4655
Mailing address
392 GOSHAWK LN, FARINA, IL 62838-3734
(618) 292-4655
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
160-003878
IL
Other
Enumeration date
11/17/2019
Last updated
11/21/2019
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