MEDICARE: NICOLE MARIA PEDERSEN

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1831895671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIA PEDERSEN

Provider Business Mailing Address
First Line	:	5101 S MARION RD APT 205
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-2807
Country	:	US
Telephone Number	:	615-804-4086
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 S SUMMIT AVE
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57197-0001
Country	:	US
Telephone Number	:	712-269-2344
Fax Number	:

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

Provider Enumeration Date	:	02/02/2023
Last Update Date	:	02/02/2023

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Directions to “ NICOLE MARIA PEDERSEN ” Practice Location

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