Healthcare Provider Details

I. General information

NPI: 1760956668
Provider Name (Legal Business Name): KATHLEEN ELIZABETH PENGELLY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 TRANSFER RD STE 21
SAINT PAUL MN
55114-1489
US

IV. Provider business mailing address

762 TRANSFER RD STE 21
SAINT PAUL MN
55114-1489
US

V. Phone/Fax

Practice location:
  • Phone: 651-659-2900
  • Fax: 651-645-7307
Mailing address:
  • Phone: 651-955-3397
  • Fax: 651-645-7307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6667
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number138239-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: