Provider Demographics
NPI:1528211836
Name:GOLDMAN, BETTEJANE KREMEN (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:BETTEJANE
Middle Name:KREMEN
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2641 NATCHEZ AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3946
Mailing Address - Country:US
Mailing Address - Phone:952-922-8865
Mailing Address - Fax:
Practice Address - Street 1:4330 CEDAR LAKE RD S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-3700
Practice Address - Country:US
Practice Address - Phone:952-381-3434
Practice Address - Fax:952-377-1430
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23317133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN535932OtherREGISTERED DIETITION
MN23317OtherBOARD OF DIETETICS AND NUTRITION LICENSE