Healthcare Provider Details

I. General information

NPI: 1104744226
Provider Name (Legal Business Name): GRACIE POLEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NUT TREE RD
VACAVILLE CA
95687-4100
US

IV. Provider business mailing address

1000 NUT TREE RD
VACAVILLE CA
95687-4100
US

V. Phone/Fax

Practice location:
  • Phone: 707-624-7810
  • Fax:
Mailing address:
  • Phone: 707-624-7810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number95290659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: