Provider Demographics
NPI:1174543680
Name:IBRAHIM, WANDA FAYE (CRNA)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:FAYE
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 WOODHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-3912
Mailing Address - Country:US
Mailing Address - Phone:423-543-1303
Mailing Address - Fax:
Practice Address - Street 1:CORNER SIDNEY AND LAMONT
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:37684
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000025064367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered