Provider Demographics
NPI:1174079917
Name:CEDERSTROM, STACY ANN (FNP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:CEDERSTROM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:ANN
Other - Last Name:TANDESKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:425 7TH STREET NORTH EAST
Mailing Address - Street 2:
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633
Mailing Address - Country:US
Mailing Address - Phone:218-335-3200
Mailing Address - Fax:218-335-3300
Practice Address - Street 1:425 7TH STREET NORTH EAST
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633
Practice Address - Country:US
Practice Address - Phone:218-335-3200
Practice Address - Fax:218-335-3300
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4566363L00000X
MNCNP4566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCNP4566OtherFNP LICENSE
MNMC3911028OtherDNP