Provider Demographics
NPI:1063471381
Name:FEARING, PENNELOPE H (ANP)
Entity Type:Individual
Prefix:
First Name:PENNELOPE
Middle Name:H
Last Name:FEARING
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 NORTHDALE BLVD NW STE 220
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3046
Mailing Address - Country:US
Mailing Address - Phone:763-537-2000
Mailing Address - Fax:763-537-6666
Practice Address - Street 1:9550 UPLAND LN N STE 100
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4482
Practice Address - Country:US
Practice Address - Phone:763-772-9820
Practice Address - Fax:763-537-6666
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNRO 76345-7363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S96108Medicare UPIN
500001099Medicare ID - Type Unspecified