Provider Demographics
NPI:1851885990
Name:WATSON, CECILIA ANN (RD)
Entity Type:Individual
Prefix:MRS
First Name:CECILIA
Middle Name:ANN
Last Name:WATSON
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 1:4855 S WACKERLI AVE
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-8154
Mailing Address - Country:US
Mailing Address - Phone:208-541-5274
Mailing Address - Fax:
Practice Address - Street 1:4855 S WACKERLI AVE
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-8154
Practice Address - Country:US
Practice Address - Phone:208-541-5274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1008133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered