Provider Demographics
NPI:1417574294
Name:VANDAGRIFF, MARTI BORDENLON (RDN LDN CDCES)
Entity Type:Individual
Prefix:MS
First Name:MARTI
Middle Name:BORDENLON
Last Name:VANDAGRIFF
Suffix:
Gender:F
Credentials:RDN LDN CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 WHITEFIELD LANE
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112
Mailing Address - Country:US
Mailing Address - Phone:318-780-0530
Mailing Address - Fax:
Practice Address - Street 1:707 S VIENNA ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270
Practice Address - Country:US
Practice Address - Phone:318-224-3044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1254133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered