Provider Demographics
NPI:1386053700
Name:WATSON, REBECCA (RD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:BORG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2600 N WYATT DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6106
Mailing Address - Country:US
Mailing Address - Phone:520-324-5437
Mailing Address - Fax:520-324-3128
Practice Address - Street 1:2600 N WYATT DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6106
Practice Address - Country:US
Practice Address - Phone:520-324-5437
Practice Address - Fax:520-324-3128
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86021319133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ934301Medicaid