Provider Demographics
NPI:1851317598
Name:JOHNSRUD, PENNY (FNP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:JOHNSRUD
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 1:3727 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 1:501 NE HOOD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7303
Practice Address - Country:US
Practice Address - Phone:503-775-4931
Practice Address - Fax:503-788-7285
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR095006656N1363LF0000X
WAAP30005364363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9636119Medicaid
OR212335Medicaid