Provider Demographics
NPI:1578316667
Name:IBRAHIM, NITA (APN)
Entity type:Individual
Prefix:
First Name:NITA
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 UNION ST
Mailing Address - Street 2:
Mailing Address - City:MOONACHIE
Mailing Address - State:NJ
Mailing Address - Zip Code:07074-1512
Mailing Address - Country:US
Mailing Address - Phone:201-562-8876
Mailing Address - Fax:
Practice Address - Street 1:357 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2519
Practice Address - Country:US
Practice Address - Phone:551-309-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14968300363LA2200X
NY311576363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health