Provider Demographics
NPI:1376125450
Name:VANDYK, TAYLOR ALEXA (MS, RDN, LD, CHES)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ALEXA
Last Name:VANDYK
Suffix:
Gender:F
Credentials:MS, RDN, LD, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 TREVINO LN APT 10
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-4443
Mailing Address - Country:US
Mailing Address - Phone:616-560-2998
Mailing Address - Fax:214-291-9792
Practice Address - Street 1:57 TREVINO LN APT 10
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-4443
Practice Address - Country:US
Practice Address - Phone:616-560-2998
Practice Address - Fax:214-291-9792
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1861133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered