MEDICARE: GINNY MARIE POLM APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	216802	OK

General Provider Information

NPI Number	:	1407612757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINNY MARIE POLM APRN

Provider Business Mailing Address
First Line	:	610 W BYPASS
Second Line	:
City	:	DRUMRIGHT
State	:	OK
Zip	:	74030-5957
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	610 W BYPASS
Second Line	:
City	:	DRUMRIGHT
State	:	OK
Zip	:	74030-5957
Country	:	US
Telephone Number	:	918-382-2300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2024
Last Update Date	:	03/01/2024

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