Provider Demographics
NPI:1316445570
Name:NUTRITION BY PETRA
Entity type:Organization
Organization Name:NUTRITION BY PETRA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:PETRA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLINDRES
Authorized Official - Suffix:
Authorized Official - Credentials:MA, RDN/LD, IBCLC
Authorized Official - Phone:405-492-6282
Mailing Address - Street 1:10913 ROCK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5222
Mailing Address - Country:US
Mailing Address - Phone:858-352-8354
Mailing Address - Fax:
Practice Address - Street 1:3261 24TH AVE NW STE 101
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6666
Practice Address - Country:US
Practice Address - Phone:405-492-6282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2053133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1407232317Medicaid
OK1912414947Medicaid