Healthcare Provider Details

I. General information

NPI: 1598437527
Provider Name (Legal Business Name): HEATHER PEDERSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER SULLIVAN

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 MAPLEWOOD DR N
MAPLEWOOD MN
55109-1913
US

IV. Provider business mailing address

1595 W WAYZATA BLVD APT B
LONG LAKE MN
55356-9699
US

V. Phone/Fax

Practice location:
  • Phone: 651-797-6880
  • Fax: 651-797-6881
Mailing address:
  • Phone: 507-317-2516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8566
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: