Provider Demographics
NPI:1437587219
Name:BASILE IBRAHIM, BRIDGET
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:BASILE IBRAHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRIDGET
Other - Middle Name:
Other - Last Name:BASILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1575 BLUE HILL AVE
Mailing Address - Street 2:MATTAPAN COMMUNITY HEALTH CENTER
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2122
Mailing Address - Country:US
Mailing Address - Phone:617-296-0061
Mailing Address - Fax:617-296-5408
Practice Address - Street 1:1575 BLUE HILL AVE
Practice Address - Street 2:MATTAPAN COMMUNITY HEALTH CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02126-2122
Practice Address - Country:US
Practice Address - Phone:617-296-0061
Practice Address - Fax:617-296-5408
Is Sole Proprietor?:No
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN270470363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily