MEDICARE: SUSAN B IBRAHIM CRFNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APN0000012438	TN

General Provider Information

NPI Number	:	1568511491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN B IBRAHIM CRFNP

Provider Business Mailing Address
First Line	:	1204 N HOUSTON LEVEE RD STE 114
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-6687
Country	:	US
Telephone Number	:	901-857-4228
Fax Number	:

Provider Business Practice Location Address
First Line	:	1204 N HOUSTON LEVEE RD STE 114
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-6687
Country	:	US
Telephone Number	:	901-421-5000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	12/06/2025

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