Provider Demographics
NPI:1578156675
Name:VARDELL, MARJORIE (MS, RD, CSOWM, LD)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:VARDELL
Suffix:
Gender:F
Credentials:MS, RD, CSOWM, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 MAPLE AVE STE 3B
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-8136
Mailing Address - Country:US
Mailing Address - Phone:214-590-8725
Mailing Address - Fax:
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-4624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81955133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered