Provider Demographics
NPI:1598437527
Name:PEDERSON, HEATHER (APRN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1595 W WAYZATA BLVD APT B
Mailing Address - Street 2:
Mailing Address - City:LONG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55356-9699
Mailing Address - Country:US
Mailing Address - Phone:507-317-2516
Mailing Address - Fax:
Practice Address - Street 1:2411 MAPLEWOOD DR N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1913
Practice Address - Country:US
Practice Address - Phone:651-797-6880
Practice Address - Fax:651-797-6881
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily