Provider Demographics
NPI:1730852609
Name:PEDERSEN, CASSANDRA ELIZABETH (RD)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:ELIZABETH
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 VICTORY AVE APT 122
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4812
Mailing Address - Country:US
Mailing Address - Phone:763-486-8335
Mailing Address - Fax:763-343-6112
Practice Address - Street 1:555 VICTORY AVE APT 122
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4812
Practice Address - Country:US
Practice Address - Phone:763-486-8335
Practice Address - Fax:763-343-6112
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3902133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered