Provider Demographics
NPI:1134264302
Name:WATERS, AMY ELIZABETH (MS, RD, IBCLC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:WATERS
Suffix:
Gender:F
Credentials:MS, RD, IBCLC
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, RD, IBCLC
Mailing Address - Street 1:1111 PINE ROOT BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:BAKERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28705-7418
Mailing Address - Country:US
Mailing Address - Phone:828-688-3631
Mailing Address - Fax:
Practice Address - Street 1:1233 SOUTHWEST AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6596
Practice Address - Country:US
Practice Address - Phone:423-979-3200
Practice Address - Fax:423-688-3261
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
EXEMPT133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered