Healthcare Provider Details

I. General information

NPI: 1235092412
Provider Name (Legal Business Name): ABIGAIL GRACE GOFORTH RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N
SAINT CLOUD MN
56303-2736
US

IV. Provider business mailing address

1200 6TH AVE N
SAINT CLOUD MN
56303-2736
US

V. Phone/Fax

Practice location:
  • Phone: 320-240-2100
  • Fax:
Mailing address:
  • Phone: 320-240-2100
  • Fax: 320-240-2834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86346764
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: