Provider Demographics
NPI:1396423497
Name:BOUALAOUI, IHSANE (FNP)
Entity type:Individual
Prefix:
First Name:IHSANE
Middle Name:
Last Name:BOUALAOUI
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 BAY RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3177
Mailing Address - Country:US
Mailing Address - Phone:718-630-1300
Mailing Address - Fax:
Practice Address - Street 1:367 BAY RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3177
Practice Address - Country:US
Practice Address - Phone:718-630-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2022152337363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily