Provider Demographics
NPI:1346472834
Name:IBRAHEEM, YAQUTULLAH (MS, RD, LD)
Entity Type:Individual
Prefix:MS
First Name:YAQUTULLAH
Middle Name:
Last Name:IBRAHEEM
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2670 MIRIAM LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-5731
Mailing Address - Country:US
Mailing Address - Phone:404-454-7356
Mailing Address - Fax:
Practice Address - Street 1:4071 CODEL ST SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-4355
Practice Address - Country:US
Practice Address - Phone:404-454-7356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003181133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1346472834OtherNPI