Provider Demographics
NPI:1861382582
Name:WATSON, LORI MARIE (RD, LDN)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:MARIE
Last Name:WATSON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:MARIE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1055 BONNIE BRAE ST NE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-8529
Mailing Address - Country:US
Mailing Address - Phone:817-368-9623
Mailing Address - Fax:
Practice Address - Street 1:1055 BONNIE BRAE ST NE
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-8529
Practice Address - Country:US
Practice Address - Phone:817-368-9623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-04
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL008688133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered