Basic Information
Provider Information | |||||||||
NPI: | 1245501584 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WATTS | ||||||||
FirstName: | KIRSTEN | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, RD, LD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 933 BRADBURY DR SE | ||||||||
Address2: | SUITE 2222 | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871064374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052723120 | ||||||||
FaxNumber: | 5052728060 | ||||||||
Practice Location | |||||||||
Address1: | DEPARTMENT OF PEDIATRICS MSC10 5590 | ||||||||
Address2: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871310001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052720826 | ||||||||
FaxNumber: | 5052726620 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2012 | ||||||||
LastUpdateDate: | 05/07/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 953636 | NM | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 133V00000X | LD-0719 | NM | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.