Basic Information
| Provider Information | |||||||||
| NPI: | 1518681360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLEN | ||||||||
| FirstName: | SHERRY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 LEACH AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870202041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052905780 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1217 BONITA ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870202103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052872958 | ||||||||
| FaxNumber: | 5052872403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2022 | ||||||||
| LastUpdateDate: | 11/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R54563 | NM | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 70171 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.