Provider Demographics
NPI:1760956668
Name:PENGELLY, KATHLEEN ELIZABETH (CNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:PENGELLY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 TRANSFER RD STE 21
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1489
Mailing Address - Country:US
Mailing Address - Phone:651-955-3397
Mailing Address - Fax:651-645-7307
Practice Address - Street 1:762 TRANSFER RD STE 21
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1489
Practice Address - Country:US
Practice Address - Phone:651-659-2900
Practice Address - Fax:651-645-7307
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6667363LP0808X
MN138239-0163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health