Provider Demographics
NPI:1407612757
Name:POLM, GINNY MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:GINNY
Middle Name:MARIE
Last Name:POLM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:GINNY
Other - Middle Name:MARIE
Other - Last Name:RIISE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:610 W BYPASS
Mailing Address - Street 2:
Mailing Address - City:DRUMRIGHT
Mailing Address - State:OK
Mailing Address - Zip Code:74030-5957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 W BYPASS
Practice Address - Street 2:
Practice Address - City:DRUMRIGHT
Practice Address - State:OK
Practice Address - Zip Code:74030-5957
Practice Address - Country:US
Practice Address - Phone:918-382-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK216802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily