Provider Demographics
NPI:1265204648
Name:GOODEN, AGAPE DIVINE (RDN)
Entity type:Individual
Prefix:
First Name:AGAPE
Middle Name:DIVINE
Last Name:GOODEN
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 1:4820 31ST ST S STE B
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22206-1665
Mailing Address - Country:US
Mailing Address - Phone:703-865-6490
Mailing Address - Fax:
Practice Address - Street 1:3903 FAIR RIDGE DR STE 209
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2944
Practice Address - Country:US
Practice Address - Phone:703-865-6490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-27
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDI200001245133V00000X
VA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered