Provider Demographics
NPI:1619354628
Name:PEDERSON, KALLI (RDN, LN, CDE)
Entity Type:Individual
Prefix:
First Name:KALLI
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:RDN, LN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 S CLIFF AVE
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1058
Mailing Address - Country:US
Mailing Address - Phone:605-322-8995
Mailing Address - Fax:
Practice Address - Street 1:1315 S CLIFF AVE
Practice Address - Street 2:SUITE 1300
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1058
Practice Address - Country:US
Practice Address - Phone:605-322-8995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0489133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered