Provider Demographics
NPI:1003900358
Name:DE WAAL, DESIREE (RD)
Entity Type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:
Last Name:DE WAAL
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 1:1 S PROSPECT ST
Mailing Address - Street 2:UHC ARNOLD 2318, RENAL CLINIC
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-3456
Mailing Address - Country:US
Mailing Address - Phone:802-847-3203
Mailing Address - Fax:802-847-3607
Practice Address - Street 1:1 S PROSPECT ST
Practice Address - Street 2:UHC ARNOLD 2318, RENAL CLINIC
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3456
Practice Address - Country:US
Practice Address - Phone:802-847-3203
Practice Address - Fax:802-847-3607
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT074-0000171133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal