Basic Information
| Provider Information | |||||||||
| NPI: | 1841283074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEDERSON | ||||||||
| FirstName: | CORALIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | WHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1619 DAYTON AVE | ||||||||
| Address2: | |||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516450478 | ||||||||
| FaxNumber: | 6516422523 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 CHURCH ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126257900 | ||||||||
| FaxNumber: | 6516422523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R131630-8 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 463972300 | 05 | MN | MEDICAID |