Provider Demographics
NPI:1275148785
Name:GOETZ, BREEANNA LYNN (RDN)
Entity Type:Individual
Prefix:MS
First Name:BREEANNA
Middle Name:LYNN
Last Name:GOETZ
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 1:25755 655TH ST
Mailing Address - Street 2:
Mailing Address - City:KASSON
Mailing Address - State:MN
Mailing Address - Zip Code:55944-1896
Mailing Address - Country:US
Mailing Address - Phone:507-990-0576
Mailing Address - Fax:
Practice Address - Street 1:25755 655TH ST
Practice Address - Street 2:
Practice Address - City:KASSON
Practice Address - State:MN
Practice Address - Zip Code:55944-1896
Practice Address - Country:US
Practice Address - Phone:507-990-0576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86103268133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered