Healthcare Provider Details

I. General information

NPI: 1649264789
Provider Name (Legal Business Name): ELIZABETH M. WATSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 41 BOX 5784
APO AE
09464
GB

IV. Provider business mailing address

PSC 41 BOX 5784
APO AE
09464
GB

V. Phone/Fax

Practice location:
  • Phone: 01638528519
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number804503
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: