Healthcare Provider Details

I. General information

NPI: 1306839865
Provider Name (Legal Business Name): PAULA LYNN PENGILLY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 12/04/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17807 US HWY 59 NE ROSE MEDICAL MANAGEMENT
THIEF RIVER FALLS MN
56701-5670
US

IV. Provider business mailing address

3461 37TH ST NE
INKSTER ND
58233-9306
US

V. Phone/Fax

Practice location:
  • Phone: 361-413-5179
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP91014
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: