Provider Demographics
NPI:1891261830
Name:IBRAHIM, SHUKRI
Entity Type:Individual
Prefix:
First Name:SHUKRI
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2313 W 19TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51103-2335
Mailing Address - Country:US
Mailing Address - Phone:712-259-1735
Mailing Address - Fax:
Practice Address - Street 1:2313 W 19TH ST APT 1
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51103-2335
Practice Address - Country:US
Practice Address - Phone:712-259-1735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA$$$$$$$$$Medicaid