Provider Demographics
NPI:1508262494
Name:PENDARVIS, BRENDA (RD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:PENDARVIS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12505 BARNES TER
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73170-3408
Mailing Address - Country:US
Mailing Address - Phone:405-380-3031
Mailing Address - Fax:
Practice Address - Street 1:12505 BARNES TER
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73170-3408
Practice Address - Country:US
Practice Address - Phone:405-380-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133VN1005X
OKLD1295133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKLD1295OtherLICENSED DIETITIAN