Healthcare Provider Details

I. General information

NPI: 1679441604
Provider Name (Legal Business Name): IBRAHIM DIAKHATE CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 KENNEDY ST
LANCASTER PA
17602-4098
US

IV. Provider business mailing address

837 HILTON DR
LANCASTER PA
17603-5835
US

V. Phone/Fax

Practice location:
  • Phone: 877-564-3627
  • Fax:
Mailing address:
  • Phone: 267-928-5058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP034381
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: