Provider Demographics
NPI:1932474566
Name:GODBOLD, KRISTINE L (RD)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:L
Last Name:GODBOLD
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 1:13901 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2720
Mailing Address - Country:US
Mailing Address - Phone:313-921-5500
Mailing Address - Fax:
Practice Address - Street 1:7900 KERCHEVAL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-2439
Practice Address - Country:US
Practice Address - Phone:313-921-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI883716133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered