Provider Demographics
NPI:1396544995
Name:ISMAIL, ILHAM
Entity type:Individual
Prefix:
First Name:ILHAM
Middle Name:
Last Name:ISMAIL
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 1:1095 CROSSINGS CT
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-5276
Mailing Address - Country:US
Mailing Address - Phone:206-661-5391
Mailing Address - Fax:
Practice Address - Street 1:1095 CROSSINGS CT
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-5276
Practice Address - Country:US
Practice Address - Phone:206-661-5391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171M00000X
171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor