Basic Information
| Provider Information | |||||||||
| NPI: | 1760956668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENGELLY | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 762 TRANSFER RD STE 21 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519553397 | ||||||||
| FaxNumber: | 6516457307 | ||||||||
| Practice Location | |||||||||
| Address1: | 762 TRANSFER RD STE 21 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516592900 | ||||||||
| FaxNumber: | 6516457307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2019 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 6667 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163WP0809X | 138239-0 | MN | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.