Provider Demographics
NPI:1316990955
Name:WATSON, WENDY SUSANNE (RD, LDN)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:SUSANNE
Last Name:WATSON
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 1:3355 VICTORIA PARK LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6453
Mailing Address - Country:US
Mailing Address - Phone:336-768-3257
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BOULEVARD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-713-6919
Practice Address - Fax:336-713-3038
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002648133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered