Provider Demographics
NPI:1366550444
Name:PEDERSON, JULIE MARIE (RN)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:MARIE
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 142
Mailing Address - Street 2:
Mailing Address - City:GALLINA
Mailing Address - State:NM
Mailing Address - Zip Code:87017-0142
Mailing Address - Country:US
Mailing Address - Phone:505-638-0182
Mailing Address - Fax:
Practice Address - Street 1:6349 HIGHWAY 550
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NM
Practice Address - Zip Code:87013
Practice Address - Country:US
Practice Address - Phone:505-289-3291
Practice Address - Fax:505-289-2320
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR26856163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse