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NPI Code Detail

MEDICARE: CRISTAL VARDEMAN RD

MEDICARE: CRISTAL VARDEMAN RD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian86152610TX
2133NN1002XNutrition Education Nutritionist
3133N00000XNutritionist
4133V00000XRegistered Dietitian

General Provider Information

NPI Number : 1942979018
Entity Type Code : Individual
Provider Name (Legal Business Name) : CRISTAL VARDEMAN RD
Provider Business Mailing Address
First Line : 4411 KINSEY DR APT 1024
Second Line :
City : TYLER
State : TX
Zip : 75703-1020
Country : US
Telephone Number : 903-392-9705
Fax Number : 430-267-3550
Provider Business Practice Location Address
First Line : 4411 KINSEY DR APT 1024
Second Line :
City : TYLER
State : TX
Zip : 75703-1020
Country : US
Telephone Number : 903-392-9705
Fax Number : 430-267-3550
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/10/2021
Last Update Date : 03/18/2026

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Directions to “ CRISTAL VARDEMAN RD” Practice Location

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