Provider Demographics
NPI:1730554114
Name:WATERS, KATRINA ELISE (RD, LD)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:ELISE
Last Name:WATERS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 INNOVATION DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5261
Mailing Address - Country:US
Mailing Address - Phone:864-400-3608
Mailing Address - Fax:
Practice Address - Street 1:2 INNOVATION DR
Practice Address - Street 2:SUITE 350
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5261
Practice Address - Country:US
Practice Address - Phone:864-400-3608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1302133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered