Provider Demographics
NPI:1407231012
Name:IBRAHIM, MARYAM (AGNP-BC)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2537
Mailing Address - Country:US
Mailing Address - Phone:732-866-0800
Mailing Address - Fax:732-866-0018
Practice Address - Street 1:901 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2537
Practice Address - Country:US
Practice Address - Phone:732-866-0800
Practice Address - Fax:732-866-0018
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2022-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307226-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health