Provider Demographics
NPI:1477895654
Name:WATSON, CARYN S (MBA, RD,LD)
Entity Type:Individual
Prefix:
First Name:CARYN
Middle Name:S
Last Name:WATSON
Suffix:
Gender:F
Credentials:MBA, RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 SUMMIT CROSSING PL
Mailing Address - Street 2:SUITE 205
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2138
Mailing Address - Country:US
Mailing Address - Phone:704-671-7850
Mailing Address - Fax:
Practice Address - Street 1:640 SUMMIT CROSSING PL
Practice Address - Street 2:SUITE 205
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2138
Practice Address - Country:US
Practice Address - Phone:704-671-7850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003874133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered