Provider Demographics
NPI:1144439506
Name:PENROSE, URSULA (NP)
Entity type:Individual
Prefix:
First Name:URSULA
Middle Name:
Last Name:PENROSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 S CLARIZZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5588
Mailing Address - Country:US
Mailing Address - Phone:812-353-3060
Mailing Address - Fax:812-353-3070
Practice Address - Street 1:995 S CLARIZZ BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401
Practice Address - Country:US
Practice Address - Phone:812-353-3060
Practice Address - Fax:812-353-3070
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002368A363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200860730Medicaid
INM400022192Medicare PIN
IN252630CMedicare PIN