Provider Demographics
NPI:1316485071
Name:PEDERSON, NICOLE L (MS,CGC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:MS,CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1901
Mailing Address - Country:US
Mailing Address - Phone:218-786-1265
Mailing Address - Fax:218-786-3767
Practice Address - Street 1:400 E THIRD STREET
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:218-786-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
No171M00000XOther Service ProvidersCase Manager/Care Coordinator