MEDICARE: PATRICIA S PEDERSEN RD,LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133NN1002X	Nutrition Education Nutritionist	ND1969	FL
2	133V00000X	Registered Dietitian	ND1969	FL

General Provider Information

NPI Number	:	1043540859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA S PEDERSEN RD,LDN

Provider Business Mailing Address
First Line	:	1609 PASADENA AVE S STE 3M
Second Line	:
City	:	SOUTH PASADENA
State	:	FL
Zip	:	33707-4563
Country	:	US
Telephone Number	:	727-289-7137
Fax Number	:	727-498-6418

Provider Business Practice Location Address
First Line	:	1609 PASADENA AVE S STE 3M
Second Line	:
City	:	SOUTH PASADENA
State	:	FL
Zip	:	33707-4563
Country	:	US
Telephone Number	:	727-289-7137
Fax Number	:	727-498-6418

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2009
Last Update Date	:	04/07/2021

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