Provider Demographics
NPI:1639651714
Name:DIALLO, IBRAHIMA T (APN)
Entity Type:Individual
Prefix:
First Name:IBRAHIMA
Middle Name:T
Last Name:DIALLO
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DUNCAN AVE APT 503
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-4300
Mailing Address - Country:US
Mailing Address - Phone:201-618-6623
Mailing Address - Fax:
Practice Address - Street 1:135 BLOOMFIELD AVE STE F
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-5902
Practice Address - Country:US
Practice Address - Phone:862-213-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY727968-1163WS0200X
390200000X
NJ26NJ01390500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WS0200XNursing Service ProvidersRegistered NurseSchoolGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program