Provider Demographics
NPI:1790752608
Name:MENKE, PENNY (CNM)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:MENKE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:
Other - Last Name:MORIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1737 BEAM AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2185
Mailing Address - Country:US
Mailing Address - Phone:651-770-3320
Mailing Address - Fax:651-770-3684
Practice Address - Street 1:1737 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2185
Practice Address - Country:US
Practice Address - Phone:651-770-3320
Practice Address - Fax:651-770-3684
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0927620367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN783717800Medicaid