Healthcare Provider Details

I. General information

NPI: 1780195644
Provider Name (Legal Business Name): BRYANNA LYNN GONDEIRO-PETRIE NU60616065
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2772 S GRAND BLVD
SPOKANE WA
99203-2526
US

IV. Provider business mailing address

2772 S GRAND BLVD
SPOKANE WA
99203-2526
US

V. Phone/Fax

Practice location:
  • Phone: 509-456-0888
  • Fax: 509-456-0999
Mailing address:
  • Phone: 509-456-0888
  • Fax: 509-456-0999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberNU60616065
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: