Healthcare Provider Details

I. General information

NPI: 1629955091
Provider Name (Legal Business Name): ASHLEA WATERS RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 SUNNYBROOK RD STE 200
RALEIGH NC
27610-1855
US

IV. Provider business mailing address

3352 HAMPTON RD
RALEIGH NC
27607-3130
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6439
  • Fax:
Mailing address:
  • Phone: 919-274-0987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL001496
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: