Healthcare Provider Details

I. General information

NPI: 1427985993
Provider Name (Legal Business Name): ANGELA LEA PEMBERTON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N
SAINT CLOUD MN
56303-2736
US

IV. Provider business mailing address

4535 YORKTOWN LN N
PLYMOUTH MN
55442-3118
US

V. Phone/Fax

Practice location:
  • Phone: 320-240-2829
  • Fax:
Mailing address:
  • Phone: 952-484-7816
  • Fax: 952-484-7816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13968
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: