Provider Demographics
NPI:1194319798
Name:VANDAME, KELLY S
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:VANDAME
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 1:5134 FLORENCE LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-7741
Mailing Address - Country:US
Mailing Address - Phone:765-413-5609
Mailing Address - Fax:
Practice Address - Street 1:100 EXECUTIVE DR STE F
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4864
Practice Address - Country:US
Practice Address - Phone:765-201-0502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty