Provider Demographics
NPI:1851037899
Name:WATSON, HEATHER DAWN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DAWN
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1841 FORT WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-1909
Mailing Address - Country:US
Mailing Address - Phone:808-681-1523
Mailing Address - Fax:808-681-1486
Practice Address - Street 1:91-1841 FORT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-1909
Practice Address - Country:US
Practice Address - Phone:808-681-1523
Practice Address - Fax:808-681-1486
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS133NN1002X
HI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education