Provider Demographics
NPI:1407232317
Name:COLINDRES, PETRA HAYLEY (MA,RDN/LD,IBCLC,CPT)
Entity Type:Individual
Prefix:MRS
First Name:PETRA
Middle Name:HAYLEY
Last Name:COLINDRES
Suffix:
Gender:F
Credentials:MA,RDN/LD,IBCLC,CPT
Other - Prefix:MRS
Other - First Name:PETRA
Other - Middle Name:HAYLEY
Other - Last Name:LUSCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,RDN/LD,IBCLC,CPT
Mailing Address - Street 1:4129 NW 45TH ST
Mailing Address - Street 2:
Mailing Address - City:OKC
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:858-352-8354
Mailing Address - Fax:
Practice Address - Street 1:4129 NW 45TH ST
Practice Address - Street 2:
Practice Address - City:OKC
Practice Address - State:OK
Practice Address - Zip Code:73112
Practice Address - Country:US
Practice Address - Phone:858-352-8354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133VN1006X, 133NN1002X, 133VN1004X
OKLP2053133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric