Provider Demographics
NPI:1871908632
Name:INGALLS, KATHLEEN L (DPT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:INGALLS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1004
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358
Mailing Address - Country:US
Mailing Address - Phone:731-613-2214
Mailing Address - Fax:731-613-2215
Practice Address - Street 1:6070 D SOUTH FIRST STREET
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358
Practice Address - Country:US
Practice Address - Phone:731-613-2214
Practice Address - Fax:731-613-2215
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446631Medicare PIN