Provider Demographics
NPI:1306839865
Name:PENGILLY, PAULA LYNN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:LYNN
Last Name:PENGILLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3461 37TH ST NE
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:ND
Mailing Address - Zip Code:58233-9306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17807 US HWY 59 NE
Practice Address - Street 2:ROSE MEDICAL MANAGEMENT
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-5670
Practice Address - Country:US
Practice Address - Phone:361-413-5179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP91014363LF0000X
WI8443363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily