Provider Demographics
NPI:1386675916
Name:GOEDEL, KATHLEEN RILEY (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:RILEY
Last Name:GOEDEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1010 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1200
Mailing Address - Country:US
Mailing Address - Phone:218-834-7200
Mailing Address - Fax:218-834-7220
Practice Address - Street 1:1010 4TH ST
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1200
Practice Address - Country:US
Practice Address - Phone:218-834-7200
Practice Address - Fax:218-834-7220
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR049321-9163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR05231Medicare UPIN