Provider Demographics
NPI:1598066672
Name:IBISANYA, JOHNSON GBENGA (LPN)
Entity Type:Individual
Prefix:
First Name:JOHNSON
Middle Name:GBENGA
Last Name:IBISANYA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 STUYVESANT AVE
Mailing Address - Street 2:8C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-2418
Mailing Address - Country:US
Mailing Address - Phone:718-801-9149
Mailing Address - Fax:
Practice Address - Street 1:50 STUYVESANT AVE
Practice Address - Street 2:8C
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-2418
Practice Address - Country:US
Practice Address - Phone:718-801-9149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303338164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse