Provider Demographics
NPI:1568511491
Name:IBRAHIM, SUSAN B (CRFNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:CRFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2484 WISHANGER CV
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38139-6618
Mailing Address - Country:US
Mailing Address - Phone:901-857-4228
Mailing Address - Fax:
Practice Address - Street 1:1204 N HOUSTON LEVEE RD STE 114
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-6687
Practice Address - Country:US
Practice Address - Phone:901-421-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000012438363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily