Provider Demographics
NPI:1104225499
Name:BUCILLA, PENNIE ELIZABETH (APRN CNP)
Entity type:Individual
Prefix:DR
First Name:PENNIE
Middle Name:ELIZABETH
Last Name:BUCILLA
Suffix:
Gender:F
Credentials:APRN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 MCANDREWS RD W
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337
Mailing Address - Country:US
Mailing Address - Phone:952-892-9393
Mailing Address - Fax:
Practice Address - Street 1:1500 MCANDREWS RD W
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-892-9393
Practice Address - Fax:952-800-8892
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR156407-9363LP0808X
MNR156407-9 CNP1972363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1104225499OtherMINNESOTA HEALTH CARE PROGRAMS (MHCP)