Provider Demographics
NPI:1861629339
Name:POLK, DEBORAH (RN)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:
Last Name:POLK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E. NIZHONI BLVD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301
Mailing Address - Country:US
Mailing Address - Phone:505-722-1790
Mailing Address - Fax:505-722-1487
Practice Address - Street 1:516 EAST NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1487
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN157409163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse