Provider Demographics
NPI:1972380699
Name:CAMARDELLE, DYLAN PAUL
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:PAUL
Last Name:CAMARDELLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4704 AMBASSADOR CAFFERY PKWY FL 3
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4704 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6908
Practice Address - Country:US
Practice Address - Phone:337-470-5920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA86176044133V00000X
LA3489133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered