Provider Demographics
NPI:1063044923
Name:KOLDENHOVEN, AGNES (RDN)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:KOLDENHOVEN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 N CHOLLA ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-4290
Mailing Address - Country:US
Mailing Address - Phone:630-927-0971
Mailing Address - Fax:
Practice Address - Street 1:2470 S VAL VISTA DR STE 104
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1693
Practice Address - Country:US
Practice Address - Phone:602-770-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL804971133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered