Healthcare Provider Details

I. General information

NPI: 1043540859
Provider Name (Legal Business Name): PATRICIA S PEDERSEN RD,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 PASADENA AVE S STE 3M
SOUTH PASADENA FL
33707-4563
US

IV. Provider business mailing address

1609 PASADENA AVE S STE 3M
SOUTH PASADENA FL
33707-4563
US

V. Phone/Fax

Practice location:
  • Phone: 727-289-7137
  • Fax: 727-498-6418
Mailing address:
  • Phone: 727-289-7137
  • Fax: 727-498-6418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberND1969
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND1969
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: