Provider Demographics
NPI:1376614958
Name:VANDERWAL, KATY J
Entity Type:Individual
Prefix:MRS
First Name:KATY
Middle Name:J
Last Name:VANDERWAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2480
Mailing Address - Country:US
Mailing Address - Phone:605-696-9000
Mailing Address - Fax:605-696-7758
Practice Address - Street 1:300 22ND AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2480
Practice Address - Country:US
Practice Address - Phone:605-696-9000
Practice Address - Fax:605-696-7758
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0313133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered