Provider Demographics
NPI:1942747506
Name:INGRAHAM, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:INGRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:CATHERINE
Other - Last Name:LASALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, FNP-BC
Mailing Address - Street 1:421 MEADOW BREEZE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-4833
Mailing Address - Country:US
Mailing Address - Phone:520-975-7189
Mailing Address - Fax:
Practice Address - Street 1:2070 NORTHBROOK BLVD STE A20
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9324
Practice Address - Country:US
Practice Address - Phone:843-953-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC233101163WC1500X
SC24644363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health