Provider Demographics
NPI:1205200904
Name:VANDEVEN, TEALA
Entity type:Individual
Prefix:
First Name:TEALA
Middle Name:
Last Name:VANDEVEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5128 SW LANDING CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-4121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5128 SW LANDING CREEK DR
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-4121
Practice Address - Country:US
Practice Address - Phone:954-383-7481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4193133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered