Provider Demographics
NPI:1841749330
Name:IBOK, IDARA (NP)
Entity Type:Individual
Prefix:
First Name:IDARA
Middle Name:
Last Name:IBOK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 FOREST GLEN RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-1460
Mailing Address - Country:US
Mailing Address - Phone:301-754-7991
Mailing Address - Fax:301-754-7990
Practice Address - Street 1:1500 FOREST GLEN RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1460
Practice Address - Country:US
Practice Address - Phone:301-754-7991
Practice Address - Fax:301-754-7990
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR171690363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily