Healthcare Provider Details

I. General information

NPI: 1700071248
Provider Name (Legal Business Name): HEATHER ANN PENNING CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 11/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 OSBORNE RD NE SUITE 220
FRIDLEY MN
55432-2773
US

IV. Provider business mailing address

480 OSBORNE RD NE SUITE 220
FRIDLEY MN
55432-2773
US

V. Phone/Fax

Practice location:
  • Phone: 763-786-1620
  • Fax: 763-780-3099
Mailing address:
  • Phone: 763-786-1620
  • Fax: 763-780-3099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR 132897-2
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR 132897-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: