Provider Demographics
NPI:1184964405
Name:VANDELICHT, PAULA ANN (RD LD)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:ANN
Last Name:VANDELICHT
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 E NIFONG BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-3708
Mailing Address - Country:US
Mailing Address - Phone:573-442-8595
Mailing Address - Fax:573-442-8652
Practice Address - Street 1:405 E NIFONG BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-3708
Practice Address - Country:US
Practice Address - Phone:573-442-8595
Practice Address - Fax:573-442-8652
Is Sole Proprietor?:No
Enumeration Date:2013-02-23
Last Update Date:2013-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001025787133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered