Provider Demographics
NPI:1225372873
Name:ABDUL-JABBAR, ISTIANAH ATIFA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:ISTIANAH
Middle Name:ATIFA
Last Name:ABDUL-JABBAR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 FLORAL AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-3244
Mailing Address - Country:US
Mailing Address - Phone:607-821-8293
Mailing Address - Fax:
Practice Address - Street 1:58 FLORAL AVE APT 10
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-3244
Practice Address - Country:US
Practice Address - Phone:607-821-8293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309852-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY309852-1OtherLICENSED PRACTICAL NURSE