Healthcare Provider Details

I. General information

NPI: 1003900358
Provider Name (Legal Business Name): DESIREE DE WAAL R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S PROSPECT ST UHC ARNOLD 2318, RENAL CLINIC
BURLINGTON VT
05401-3456
US

IV. Provider business mailing address

1 S PROSPECT ST UHC ARNOLD 2318, RENAL CLINIC
BURLINGTON VT
05401-3456
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-3203
  • Fax: 802-847-3607
Mailing address:
  • Phone: 802-847-3203
  • Fax: 802-847-3607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number074-0000171
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: