Provider Demographics
NPI:1780195644
Name:GONDEIRO-PETRIE, BRYANNA LYNN (NU60616065)
Entity Type:Individual
Prefix:
First Name:BRYANNA
Middle Name:LYNN
Last Name:GONDEIRO-PETRIE
Suffix:
Gender:F
Credentials:NU60616065
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2772 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-2526
Mailing Address - Country:US
Mailing Address - Phone:509-456-0888
Mailing Address - Fax:509-456-0999
Practice Address - Street 1:2772 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-2526
Practice Address - Country:US
Practice Address - Phone:509-456-0888
Practice Address - Fax:509-456-0999
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU60616065133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WANU60616065OtherNUTRITIONIST CERTIFICATION