Healthcare Provider Details

I. General information

NPI: 1831873744
Provider Name (Legal Business Name): PEDERSEN WELLNESS AND REJUVENATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/26/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 GRANDE BLVD SE STE E15
RIO RANCHO NM
87124-1799
US

IV. Provider business mailing address

9108 MANRESA DR NW
ALBUQUERQUE NM
87114-6471
US

V. Phone/Fax

Practice location:
  • Phone: 505-507-1584
  • Fax:
Mailing address:
  • Phone: 806-543-1429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KELLY ERIKA PEDERSEN
Title or Position: OWNER
Credential: LMHC
Phone: 806-543-1429