Provider Demographics
NPI:1962259267
Name:PEDERSEN, MICHELLE ROSE (ACNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSE
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ROSE
Other - Last Name:CLAYTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16601 N 40TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3356
Mailing Address - Country:US
Mailing Address - Phone:602-633-3721
Mailing Address - Fax:602-953-5466
Practice Address - Street 1:16601 N 40TH ST STE 204
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3356
Practice Address - Country:US
Practice Address - Phone:602-633-3721
Practice Address - Fax:602-953-5466
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN197112363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care