Healthcare Provider Details

I. General information

NPI: 1225338627
Provider Name (Legal Business Name): ANDREA NICOLE POLSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 11/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HIGHWAY 56 & 270 JUNCTION BARKING WATER ROAD
WEWOKA OK
74884-1475
US

IV. Provider business mailing address

P.O. BOX 1475 BARKING WATER ROAD
WEWOKA OK
74884-1475
US

V. Phone/Fax

Practice location:
  • Phone: 405-257-6282
  • Fax: 405-257-3344
Mailing address:
  • Phone: 405-257-6282
  • Fax: 405-257-3344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number0084059
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number0084059
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number0084059
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: