Provider Demographics
NPI:1932213147
Name:PEDERSEN, DAWN ELAINE (APRN-BC)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:ELAINE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E AMBER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-3425
Mailing Address - Country:US
Mailing Address - Phone:507-235-2605
Mailing Address - Fax:
Practice Address - Street 1:18275 KENRICK AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7306
Practice Address - Country:US
Practice Address - Phone:952-892-5400
Practice Address - Fax:952-892-5454
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN155646-9363LF0000X
IAA-092130363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP57029Medicare UPIN