Provider Demographics
NPI:1174180640
Name:PEDERSON, KATHRYN L
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:MN
Mailing Address - Zip Code:56273-9796
Mailing Address - Country:US
Mailing Address - Phone:320-444-5065
Mailing Address - Fax:
Practice Address - Street 1:201 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:MN
Practice Address - Zip Code:56273-9796
Practice Address - Country:US
Practice Address - Phone:320-444-5065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion