Provider Demographics
NPI:1942979018
Name:VARDEMAN, CRISTAL (RD)
Entity Type:Individual
Prefix:
First Name:CRISTAL
Middle Name:
Last Name:VARDEMAN
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 1:4411 KINSEY DR APT 1024
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1020
Mailing Address - Country:US
Mailing Address - Phone:936-465-1168
Mailing Address - Fax:
Practice Address - Street 1:4411 KINSEY DR APT 1024
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1020
Practice Address - Country:US
Practice Address - Phone:936-465-1168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133NN1002X, 133V00000X
TX86152610133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education