Provider Demographics
NPI:1073272688
Name:HANEY-GOELZ, KENNEDY (MS RDN LD)
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:
Last Name:HANEY-GOELZ
Suffix:
Gender:F
Credentials:MS RDN LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 GOWAN AVE SW
Mailing Address - Street 2:
Mailing Address - City:HOWARD LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55349-5218
Mailing Address - Country:US
Mailing Address - Phone:763-222-7047
Mailing Address - Fax:
Practice Address - Street 1:5354 PARKDALE DR
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-1603
Practice Address - Country:US
Practice Address - Phone:888-364-5977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4608133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered