Provider Demographics
NPI:1174297899
Name:SANNI, IBRAHIM OMOBOLA
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:OMOBOLA
Last Name:SANNI
Suffix:
Gender:M
Credentials:
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 622
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30048-0622
Mailing Address - Country:US
Mailing Address - Phone:470-549-3923
Mailing Address - Fax:
Practice Address - Street 1:1053 HILL ST SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-1903
Practice Address - Country:US
Practice Address - Phone:470-549-3923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
84-5109387OtherIRS