Provider Demographics
NPI:1760075337
Name:MANSARAY, IBRAHIM
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:MANSARAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 KENILWORTH AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-2010
Mailing Address - Country:US
Mailing Address - Phone:202-603-3854
Mailing Address - Fax:410-946-2010
Practice Address - Street 1:1615 KENILWORTH AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-2010
Practice Address - Country:US
Practice Address - Phone:202-588-8036
Practice Address - Fax:410-946-2010
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00154888374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide