Healthcare Provider Details

I. General information

NPI: 1659935070
Provider Name (Legal Business Name): JANINE PEDERSEN APNP-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. JANINE PEDERSEN CHANG

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY STREET APC MAIN
PROVIDENCE RI
02903
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-5435
  • Fax: 401-444-8301
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN02032
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN02032
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: