Provider Demographics
NPI:1689130080
Name:WATERS, TRINIQUE (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:TRINIQUE
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 W ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-1015
Mailing Address - Country:US
Mailing Address - Phone:443-414-7332
Mailing Address - Fax:
Practice Address - Street 1:1512 SOUTH ST FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1636
Practice Address - Country:US
Practice Address - Phone:267-239-5637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006117133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered