Provider Demographics
NPI:1043540859
Name:PEDERSEN, PATRICIA S (RD,LDN)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:S
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 PASADENA AVE S STE 3M
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4563
Mailing Address - Country:US
Mailing Address - Phone:727-289-7137
Mailing Address - Fax:727-498-6418
Practice Address - Street 1:1609 PASADENA AVE S STE 3M
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4563
Practice Address - Country:US
Practice Address - Phone:727-289-7137
Practice Address - Fax:727-498-6418
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND1969133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP86962Medicare UPIN