| Street | Jalan Manunggal | ||
| City/Town | Balikpapan | ||
| State/Province/Region | Kalimantan Timur | ||
| Zip/Postal Code | 76113 | ||
| Phone Number | (0542) 7027106 | ||
| Country | Indonesia |
| Full Name | Azalea Kani Halimah M.Farm | ||
| Gender | female | ||
| Birthday | 1975-09-26 | ||
| Social Security Number |
| Credit card brand | American Express | ||
| Credit card number | 370322658887864 | ||
| Expire | 2027/4 | ||
| CVV | 119 |