Provider Demographics
NPI:1003684762
Name:DOMINGO-ZAHIRUDDIN, MARISSA GABONA (RDN, LDN)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:GABONA
Last Name:DOMINGO-ZAHIRUDDIN
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:GABONA
Other - Last Name:DOMINGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDN, LDN
Mailing Address - Street 1:8112 CRAWFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-3330
Mailing Address - Country:US
Mailing Address - Phone:773-787-9161
Mailing Address - Fax:
Practice Address - Street 1:8112 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-3330
Practice Address - Country:US
Practice Address - Phone:773-787-9161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164008791133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered