Provider Demographics
NPI:1508134560
Name:GODFREY, KRISTA MARIE (RD)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:MARIE
Last Name:GODFREY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N 90TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2764
Mailing Address - Country:US
Mailing Address - Phone:403-955-6191
Mailing Address - Fax:
Practice Address - Street 1:8200 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4113
Practice Address - Country:US
Practice Address - Phone:402-955-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2014-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1021133NN1002X, 133V00000X, 133VN1004X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
133VN1004XOtherPEDIATRIC NUTRITION
NE133VN1004XMedicaid