Provider Demographics
NPI:1952929283
Name:GOODFELLOW, HALEY NICHOLE (RD, LDN)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:NICHOLE
Last Name:GOODFELLOW
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2079
Mailing Address - Country:US
Mailing Address - Phone:618-531-6029
Mailing Address - Fax:
Practice Address - Street 1:60 S STATE ROUTE 157
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3846
Practice Address - Country:US
Practice Address - Phone:618-655-8147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020013164133V00000X
IL164008029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered