Provider Demographics
NPI:1265468912
Name:PENGELLY, PHYLLIS A (WHNP)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:A
Last Name:PENGELLY
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3727 NE MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-1112
Mailing Address - Country:US
Mailing Address - Phone:503-775-4931
Mailing Address - Fax:503-788-7285
Practice Address - Street 1:2330 NE DIVISION ST
Practice Address - Street 2:SUITE 7
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3530
Practice Address - Country:US
Practice Address - Phone:503-775-4931
Practice Address - Fax:503-788-7285
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350128NP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR270097Medicaid