Provider Demographics
NPI:1386849057
Name:KUSSMAUL, VICKI LEE (RD)
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:LEE
Last Name:KUSSMAUL
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 1:6000 STERLING DR
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-7632
Mailing Address - Country:US
Mailing Address - Phone:817-581-1109
Mailing Address - Fax:
Practice Address - Street 1:1600 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6913
Practice Address - Country:US
Practice Address - Phone:817-685-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05147133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered