Provider Demographics
NPI:1760457964
Name:PEDERSEN, GENEVA L (APRN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:GENEVA
Middle Name:L
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 LAPORTE RD
Mailing Address - Street 2:PO BOX 608
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661
Mailing Address - Country:US
Mailing Address - Phone:802-888-2448
Mailing Address - Fax:
Practice Address - Street 1:1126 LAPORTE RD
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661
Practice Address - Country:US
Practice Address - Phone:802-888-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0074886363LF0000X
MA178714363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
S9753Medicare UPIN