Provider Demographics
NPI:1053822098
Name:VANDER VIS, GERALYN ANN (RD)
Entity Type:Individual
Prefix:MRS
First Name:GERALYN
Middle Name:ANN
Last Name:VANDER VIS
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:PO BOX 496
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:CA
Mailing Address - Zip Code:93510-0496
Mailing Address - Country:US
Mailing Address - Phone:661-269-8212
Mailing Address - Fax:
Practice Address - Street 1:335 E AVENUE I
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-1916
Practice Address - Country:US
Practice Address - Phone:661-471-4336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA701164133V00000X
IL701164133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered