=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255004180
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IBRAHIM ALI IBRAHIM ARNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2021
-----------------------------------------------------
Last Update Date | 07/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4702 DAVIS AVE S APT BB202
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98055-8239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-697-8181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4702 DAVIS AVE S APT BB202
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98055-8239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-697-8181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 61151275
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------