Provider Demographics
NPI:1831846021
Name:BEDGOOD, DESIRAE NICOLE (RDN, LDN)
Entity type:Individual
Prefix:
First Name:DESIRAE
Middle Name:NICOLE
Last Name:BEDGOOD
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-4942
Mailing Address - Country:US
Mailing Address - Phone:318-200-0491
Mailing Address - Fax:
Practice Address - Street 1:1500 N 19TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-4942
Practice Address - Country:US
Practice Address - Phone:318-200-0491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3278133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered