Healthcare Provider Details

I. General information

NPI: 1528925823
Provider Name (Legal Business Name): SHANICE LOUISE IBRAHIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANICE LOUISE THOMPSON

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 LIBERTY ST
SPRINGFIELD MA
01104-3736
US

IV. Provider business mailing address

417 LIBERTY ST
SPRINGFIELD MA
01104-3736
US

V. Phone/Fax

Practice location:
  • Phone: 413-733-6661
  • Fax: 413-733-7841
Mailing address:
  • Phone: 413-733-6661
  • Fax: 413-733-7841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLN94386
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: