Healthcare Provider Details

I. General information

NPI: 1518681360
Provider Name (Legal Business Name): SHERRY ANN POLEN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 BONITA ST
GRANTS NM
87020-2103
US

IV. Provider business mailing address

504 LEACH AVE
GRANTS NM
87020-2041
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-2958
  • Fax: 505-287-2403
Mailing address:
  • Phone: 505-290-5780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR54563
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number70171
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: