Provider Demographics
NPI:1134286651
Name:QIBLAWI, MARY ELISABETH (RD, CD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELISABETH
Last Name:QIBLAWI
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5839 W EDGERTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4923
Mailing Address - Country:US
Mailing Address - Phone:414-421-7440
Mailing Address - Fax:
Practice Address - Street 1:5900 S LAKE DR
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-3171
Practice Address - Country:US
Practice Address - Phone:414-489-4532
Practice Address - Fax:414-489-4217
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1082-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1082-029OtherSTATE OF WI CREDENTIAL