Provider Demographics
NPI:1013984491
Name:RUBESH, PENNY L (FNP)
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:L
Last Name:RUBESH
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 1:1555 NORTHWAY DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4913
Mailing Address - Country:US
Mailing Address - Phone:320-240-3157
Mailing Address - Fax:320-240-3143
Practice Address - Street 1:1555 NORTHWAY DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4913
Practice Address - Country:US
Practice Address - Phone:320-240-3157
Practice Address - Fax:320-240-3143
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMNR1163739363LF0000X
MNR-116373-9363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN186660500Medicaid
MN500002498Medicare ID - Type Unspecified
MN186660500Medicaid