Provider Demographics
NPI:1548720055
Name:IBRAHIM, CANDACE
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08562-2015
Mailing Address - Country:US
Mailing Address - Phone:609-752-2357
Mailing Address - Fax:
Practice Address - Street 1:22 GORDON AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-1033
Practice Address - Country:US
Practice Address - Phone:609-844-0452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ009116002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry