Healthcare Provider Details

I. General information

NPI: 1881784874
Provider Name (Legal Business Name): SHELLY ANN WATSON RD,LD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GYPSY LANE NORTHSIDE MEDICAL CENTER
YOUNGSTOWN OH
44501-1315
US

IV. Provider business mailing address

334 IMPERIAL ST
YOUNGSTOWN OH
44509-1160
US

V. Phone/Fax

Practice location:
  • Phone: 330-884-3427
  • Fax: 330-884-3433
Mailing address:
  • Phone: 330-792-0139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4291
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: