Provider Demographics
NPI:1215369293
Name:WATKINS, CASSI MENDIOLA (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:CASSI
Middle Name:MENDIOLA
Last Name:WATKINS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6267
Mailing Address - Country:US
Mailing Address - Phone:208-381-4011
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6267
Practice Address - Country:US
Practice Address - Phone:208-381-4011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID86013281133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered