Basic Information
| Provider Information | |||||||||
| NPI: | 1891241774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEDERSEN | ||||||||
| FirstName: | KARI | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAESSLE | ||||||||
| OtherFirstName: | KARI | ||||||||
| OtherMiddleName: | E. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 530 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458041500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5673714418 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 437 WOODSIDE LAKE DR | ||||||||
| Address2: | |||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432305078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133686271 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2016 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 019802 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0185398 | 05 | OH | MEDICAID |