Provider Demographics
NPI:1528385176
Name:PEDERSEN, GRACE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 DUNLAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-2913
Mailing Address - Country:US
Mailing Address - Phone:386-675-4411
Mailing Address - Fax:386-675-4419
Practice Address - Street 1:1211 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-2913
Practice Address - Country:US
Practice Address - Phone:386-675-4411
Practice Address - Fax:386-675-4419
Is Sole Proprietor?:No
Enumeration Date:2010-04-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1617512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily