Provider Demographics
NPI:1598095556
Name:WATTERSON, LISA KRISTOF (RD)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:KRISTOF
Last Name:WATTERSON
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 1:218 WINDMERE DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-8764
Mailing Address - Country:US
Mailing Address - Phone:615-438-4250
Mailing Address - Fax:270-599-1526
Practice Address - Street 1:218 WINDMERE DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-8764
Practice Address - Country:US
Practice Address - Phone:615-438-4250
Practice Address - Fax:270-599-1526
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY2000133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered