Provider Demographics
NPI:1225694789
Name:IBARRA RODRIGUEZ, IDA MARIE (RD)
Entity Type:Individual
Prefix:MRS
First Name:IDA
Middle Name:MARIE
Last Name:IBARRA RODRIGUEZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2692 BRADEN WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-8571
Mailing Address - Country:US
Mailing Address - Phone:787-922-2177
Mailing Address - Fax:
Practice Address - Street 1:2692 BRADEN WAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-8571
Practice Address - Country:US
Practice Address - Phone:787-922-2177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY240942133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered