Healthcare Provider Details

I. General information

NPI: 1558633222
Provider Name (Legal Business Name): POLLY A DIEHL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2012
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S NATIONAL AVE FL 5
SPRINGFIELD MO
65807-5210
US

IV. Provider business mailing address

PO BOX 4046
SPRINGFIELD MO
65808-4046
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-7728
  • Fax: 417-269-7729
Mailing address:
  • Phone: 417-269-5712
  • Fax: 417-269-4869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2012002556
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: