Individual
PENNY JOHNSRUD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
501 NE HOOD AVE, SUITE 100, GRESHAM, OR 97030-7303
(503) 775-4931
(503) 788-7285
Mailing address
3727 NE MARTIN LUTHER KING JR BLVD, ATTN: CREDENTIALING, PORTLAND, OR 97212-1112
(503) 775-4931
(503) 788-7285
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
095006656N1
OR
363LF0000X
Family Nurse Practitioner
AP30005364
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
212335
—
OR
05
—
9636119
—
WA
Enumeration date
07/14/2006
Last updated
11/11/2011
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