Healthcare Provider Details

I. General information

NPI: 1265468912
Provider Name (Legal Business Name): PHYLLIS A PENGELLY WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 NE DIVISION ST SUITE 7
BEND OR
97701-3530
US

IV. Provider business mailing address

3727 NE MARTIN LUTHER KING JR BLVD ATTN: CREDENTIALING
PORTLAND OR
97212-1112
US

V. Phone/Fax

Practice location:
  • Phone: 503-775-4931
  • Fax: 503-788-7285
Mailing address:
  • Phone: 503-775-4931
  • Fax: 503-788-7285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number200350128NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: