Provider Demographics
NPI:1376857383
Name:WATKINS, SUSAN (RD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WATKINS
Suffix:
Gender:F
Credentials:RD
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 VALENCIA MESA DR STE 105
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3816
Mailing Address - Country:US
Mailing Address - Phone:714-444-5050
Mailing Address - Fax:
Practice Address - Street 1:100 E VALENCIA MESA DR
Practice Address - Street 2:SUITE 105
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3813
Practice Address - Country:US
Practice Address - Phone:714-446-5640
Practice Address - Fax:714-446-5625
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARD883073133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered