| Street | Jl.Tanjung Ria No 5 Dok 9, Jayapura | ||
| City/Town | Jayapura | ||
| State/Province/Region | Papua | ||
| Zip/Postal Code | 99111 | ||
| Phone Number | (0967) 543133 | ||
| Country | Indonesia |
| Full Name | Intan Pratiwi S.Pd | ||
| Gender | female | ||
| Birthday | 1991-08-26 | ||
| Social Security Number |
| Credit card brand | American Express | ||
| Credit card number | 379542056282571 | ||
| Expire | 2030/7 | ||
| CVV | 527 |