Provider Demographics
NPI:1912677410
Name:KOUROUMA, IBRAHIMA
Entity Type:Individual
Prefix:
First Name:IBRAHIMA
Middle Name:
Last Name:KOUROUMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 MYRTLE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-6607
Mailing Address - Country:US
Mailing Address - Phone:973-943-3768
Mailing Address - Fax:
Practice Address - Street 1:216 MYRTLE AVE APT 2
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-6607
Practice Address - Country:US
Practice Address - Phone:973-943-3768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01180000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NJ01180000OtherNJ