Provider Demographics
NPI:1043648744
Name:PENNELL, KATHRYN R (APRN, FNP-BC)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:R
Last Name:PENNELL
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:R
Other - Last Name:ROGGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, CNP
Mailing Address - Street 1:10400 HALIGUS RD
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-9553
Mailing Address - Country:US
Mailing Address - Phone:224-654-0040
Mailing Address - Fax:224-654-0027
Practice Address - Street 1:10350 HALIGUS RD STE 200D
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9545
Practice Address - Country:US
Practice Address - Phone:847-802-7280
Practice Address - Fax:847-802-7275
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010782363LF0000X
IL209010782363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400124968OtherMEDICARE PTAN
ILF400124968OtherMEDICARE PTAN