Provider Demographics
NPI:1104599406
Name:IBRAHIM, MARIE GRAF (RDN)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:GRAF
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2744 DEER TRACK WAY
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-1746
Mailing Address - Country:US
Mailing Address - Phone:727-648-3559
Mailing Address - Fax:
Practice Address - Street 1:924 ALT 19
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-4337
Practice Address - Country:US
Practice Address - Phone:727-773-7268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-01
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4995133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered