Provider Demographics
NPI:1134733470
Name:BLANTON, CAMILLA (RD, LD, CEDS)
Entity type:Individual
Prefix:
First Name:CAMILLA
Middle Name:
Last Name:BLANTON
Suffix:
Gender:F
Credentials:RD, LD, CEDS
Other - Prefix:
Other - First Name:CAMILLA
Other - Middle Name:
Other - Last Name:AHLQVIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:8000 RESEARCH FOREST DR
Mailing Address - Street 2:STE 115 PMB 1101
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8000 RESEARCH FOREST DR
Practice Address - Street 2:STE 115-1101
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77382
Practice Address - Country:US
Practice Address - Phone:469-321-6064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86143560133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered