Provider Demographics
NPI:1407486590
Name:LEISURE, POLLY JO (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:JO
Last Name:LEISURE
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5061 NICHOLAS DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35215-4064
Mailing Address - Country:US
Mailing Address - Phone:205-352-7581
Mailing Address - Fax:
Practice Address - Street 1:24276 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625-8021
Practice Address - Country:US
Practice Address - Phone:605-964-7724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-155980163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse