Provider Demographics
NPI:1558052498
Name:GOODFRIEND, RENEE MARIE (RD LD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:MARIE
Last Name:GOODFRIEND
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N PERSHING ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3933
Mailing Address - Country:US
Mailing Address - Phone:913-378-6591
Mailing Address - Fax:
Practice Address - Street 1:115 N PERSHING ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3933
Practice Address - Country:US
Practice Address - Phone:913-378-6591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1708133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered