Provider Demographics
NPI:1063566685
Name:PEDERSEN, LONDA LENAE (MS)
Entity type:Individual
Prefix:MRS
First Name:LONDA
Middle Name:LENAE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 E CAPITOL AVE APT 311
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-2385
Mailing Address - Country:US
Mailing Address - Phone:701-720-2302
Mailing Address - Fax:
Practice Address - Street 1:7080 8TH AVE
Practice Address - Street 2:
Practice Address - City:CANNON BALL
Practice Address - State:ND
Practice Address - Zip Code:58528-9518
Practice Address - Country:US
Practice Address - Phone:701-854-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51338Medicaid