Provider Demographics
NPI:1992974422
Name:PEDERSEN, ANNETTE L (RDN, LD, CDE)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:L
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:RDN, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9417 BROADVIEW RD
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-2307
Mailing Address - Country:US
Mailing Address - Phone:330-388-7894
Mailing Address - Fax:
Practice Address - Street 1:9417 BROADVIEW RD
Practice Address - Street 2:
Practice Address - City:BROADVIEW HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44147-2307
Practice Address - Country:US
Practice Address - Phone:330-388-7894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH288780163WD0400X
OHLD2323133V00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator