Provider Demographics
NPI:1760707855
Name:VANDERWALL, CASSANDRA MAE (MS,RD,CPT)
Entity Type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:MAE
Last Name:VANDERWALL
Suffix:
Gender:F
Credentials:MS,RD,CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 HIGHLAND AVE
Mailing Address - Street 2:F4/120
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-1510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:F4/120
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-1510
Practice Address - Country:US
Practice Address - Phone:847-707-6145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005116133V00000X
WI2508-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered