Basic Information
| Provider Information | |||||||||
| NPI: | 1336266048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRYSDALE | ||||||||
| FirstName: | ANTONIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | NUTR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4588 | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778054588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798226467 | ||||||||
| FaxNumber: | 9798219448 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 E 24TH ST | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778035303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798226467 | ||||||||
| FaxNumber: | 9798219448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT00515 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | DT00515 | 01 | TX | DIETITIANS STATE LINCENSE | OTHER | 126130708 | 05 | TX | MEDICAID |