Provider Demographics
NPI:1467102020
Name:WATKINS, ADRIENNE S (RDN)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:S
Last Name:WATKINS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 N STONE MILL RD STE B
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-9320
Mailing Address - Country:US
Mailing Address - Phone:812-929-2193
Mailing Address - Fax:888-789-8394
Practice Address - Street 1:501 S MADISON ST STE 105
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2452
Practice Address - Country:US
Practice Address - Phone:812-929-2193
Practice Address - Fax:888-789-8394
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-26
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002322A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26-3890332Medicaid