Provider Demographics
NPI:1205203528
Name:PEDERSEN, SHANELLE NICOLETTE (ARNP)
Entity Type:Individual
Prefix:
First Name:SHANELLE
Middle Name:NICOLETTE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SHANELLE
Other - Middle Name:NICOLETTE
Other - Last Name:KAHRS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:308 N MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAMPTON
Mailing Address - State:IA
Mailing Address - Zip Code:50659-1142
Mailing Address - Country:US
Mailing Address - Phone:641-394-2151
Mailing Address - Fax:641-394-1999
Practice Address - Street 1:308 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:NEW HAMPTON
Practice Address - State:IA
Practice Address - Zip Code:50659-1142
Practice Address - Country:US
Practice Address - Phone:641-394-2151
Practice Address - Fax:641-394-1999
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA132210363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily