Healthcare Provider Details

I. General information

NPI: 1265997340
Provider Name (Legal Business Name): PENNY M HORMANN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKE TRAVERSE DR
SISSETON SD
57262-7046
US

IV. Provider business mailing address

73192 390TH ST
ORTONVILLE MN
56278-2109
US

V. Phone/Fax

Practice location:
  • Phone: 605-698-7606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6415
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: