Healthcare Provider Details

I. General information

NPI: 1316445570
Provider Name (Legal Business Name): NUTRITION BY PETRA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 24TH AVE NW STE 101
NORMAN OK
73069-6666
US

IV. Provider business mailing address

10913 ROCK RIDGE RD
OKLAHOMA CITY OK
73120-5222
US

V. Phone/Fax

Practice location:
  • Phone: 405-492-6282
  • Fax:
Mailing address:
  • Phone: 858-352-8354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2053
License Number StateOK

VIII. Authorized Official

Name: PETRA COLINDRES
Title or Position: OWNER, DIETITIAN
Credential: MA, RDN/LD, IBCLC
Phone: 405-492-6282