Healthcare Provider Details

I. General information

NPI: 1003790908
Provider Name (Legal Business Name): WISAL IBRAHEEM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 KILBY AVE
SUFFOLK VA
23434-5940
US

IV. Provider business mailing address

522 KILBY AVE
SUFFOLK VA
23434-5940
US

V. Phone/Fax

Practice location:
  • Phone: 860-625-2339
  • Fax:
Mailing address:
  • Phone: 860-625-2339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: