Provider Demographics
NPI:1275063968
Name:VANDE KAMP, MICHAL VICTORIA
Entity Type:Individual
Prefix:MRS
First Name:MICHAL
Middle Name:VICTORIA
Last Name:VANDE KAMP
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MICHAL
Other - Middle Name:VICTORIA
Other - Last Name:ERISMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:3101 BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3101 BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2659
Practice Address - Country:US
Practice Address - Phone:816-960-8949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered