Provider Demographics
NPI:1558602979
Name:WATTERS, CHRISTINA L (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:L
Last Name:WATTERS
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:MISS
Other - First Name:CHRISTINA
Other - Middle Name:L
Other - Last Name:MITZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD
Mailing Address - Street 1:2930 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-4757
Mailing Address - Country:US
Mailing Address - Phone:309-793-0684
Mailing Address - Fax:
Practice Address - Street 1:2930 18TH AVE
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-4757
Practice Address - Country:US
Practice Address - Phone:309-793-0684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004912133V00000X
IA001981133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered