Provider Demographics
NPI:1831895671
Name:PEDERSEN, NICOLE MARIA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIA
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 S MARION RD APT 205
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-2807
Mailing Address - Country:US
Mailing Address - Phone:615-804-4086
Mailing Address - Fax:
Practice Address - Street 1:2001 S SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57197-0001
Practice Address - Country:US
Practice Address - Phone:712-269-2344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program