Provider Demographics
NPI:1699875351
Name:VANDER KOY, DENISE S (RD CDE)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:S
Last Name:VANDER KOY
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E VETERANS ST
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-3105
Mailing Address - Country:US
Mailing Address - Phone:715-321-3208
Mailing Address - Fax:
Practice Address - Street 1:500 E VETERANS ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-3105
Practice Address - Country:US
Practice Address - Phone:715-321-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI812133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000371630Medicare ID - Type Unspecified