Provider Demographics
NPI:1295352862
Name:IBRAHIM, IANA (LAC)
Entity type:Individual
Prefix:
First Name:IANA
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 W EARLY AVE
Mailing Address - Street 2:
Mailing Address - City:COALDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18218-1129
Mailing Address - Country:US
Mailing Address - Phone:646-239-0029
Mailing Address - Fax:
Practice Address - Street 1:260 GATEWAY DR STE 11-12A
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4268
Practice Address - Country:US
Practice Address - Phone:410-900-2227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02749171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist