Provider Demographics
NPI:1629395926
Name:KHALILI, MARYAM (RD)
Entity Type:Individual
Prefix:MS
First Name:MARYAM
Middle Name:
Last Name:KHALILI
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 1:2332 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4867
Mailing Address - Country:US
Mailing Address - Phone:805-220-8182
Mailing Address - Fax:
Practice Address - Street 1:1424 COUNTY ROAD 223
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7287
Practice Address - Country:US
Practice Address - Phone:970-759-2142
Practice Address - Fax:970-375-1609
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered