Healthcare Provider Details

I. General information

NPI: 1760075337
Provider Name (Legal Business Name): IBRAHIM MANSARAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2021
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 KENILWORTH AVE NE
WASHINGTON DC
20019-2010
US

IV. Provider business mailing address

1615 KENILWORTH AVE NE
WASHINGTON DC
20019-2010
US

V. Phone/Fax

Practice location:
  • Phone: 202-588-8036
  • Fax: 410-946-2010
Mailing address:
  • Phone: 202-603-3854
  • Fax: 410-946-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberA00154888
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: