Provider Demographics
NPI:1003328667
Name:INGHAM, PHYLLIS ANNETTE (NP-C)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ANNETTE
Last Name:INGHAM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1027
Practice Address - Country:US
Practice Address - Phone:260-569-2120
Practice Address - Fax:260-569-2121
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009335A363L00000X
TXAP134764363LF0000X
NMCNP-03521363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily