Provider Demographics
NPI:1366158529
Name:RUPPERT, PENELOPE GRACE
Entity type:Individual
Prefix:
First Name:PENELOPE
Middle Name:GRACE
Last Name:RUPPERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572B LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2308
Mailing Address - Country:US
Mailing Address - Phone:847-501-4040
Mailing Address - Fax:847-501-4075
Practice Address - Street 1:572B LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-2308
Practice Address - Country:US
Practice Address - Phone:847-501-4040
Practice Address - Fax:847-501-4075
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026393363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics