Provider Demographics
NPI:1013897552
Name:GALIC, MARA IVANKA (MHSC, RD)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:IVANKA
Last Name:GALIC
Suffix:
Gender:F
Credentials:MHSC, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5332 VININGS LAKE VW SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2542
Mailing Address - Country:US
Mailing Address - Phone:404-441-4029
Mailing Address - Fax:
Practice Address - Street 1:5332 VININGS LAKE VW SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-2542
Practice Address - Country:US
Practice Address - Phone:404-441-4029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA930413133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty