Provider Demographics
NPI:1073573762
Name:IBARRA, ROSA LINDA (BS,RD,LD)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:LINDA
Last Name:IBARRA
Suffix:
Gender:F
Credentials:BS,RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 N CAGE BLVD STE I-J
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-3102
Mailing Address - Country:US
Mailing Address - Phone:956-787-6600
Mailing Address - Fax:
Practice Address - Street 1:131 FM 3168
Practice Address - Street 2:
Practice Address - City:RAYMONDVILLE
Practice Address - State:TX
Practice Address - Zip Code:78580-3605
Practice Address - Country:US
Practice Address - Phone:956-689-2196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80097133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT80097OtherLICENSE