Provider Demographics
NPI:1841283074
Name:PEDERSON, CORALIE ANN (WHNP)
Entity type:Individual
Prefix:
First Name:CORALIE
Middle Name:ANN
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CHURCH ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0222
Mailing Address - Country:US
Mailing Address - Phone:612-625-8400
Mailing Address - Fax:612-677-3321
Practice Address - Street 1:410 CHURCH ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0222
Practice Address - Country:US
Practice Address - Phone:612-625-8400
Practice Address - Fax:612-677-3321
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR131630-8363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN463972300Medicaid