1730411059 NPI number — MRS. KIMBERLY DAWN POLK APN

Table of content: MRS. KIMBERLY DAWN POLK APN (NPI 1730411059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730411059 NPI number — MRS. KIMBERLY DAWN POLK APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLK
Provider First Name:
KIMBERLY
Provider Middle Name:
DAWN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHANNON
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730411059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1000 DEPT 941
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38101-0941
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-726-0843
Provider Business Mailing Address Fax Number:
901-278-2695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 EASTMORELAND AVE
Provider Second Line Business Practice Location Address:
STE 550
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38104-7507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-726-0843
Provider Business Practice Location Address Fax Number:
901-278-2695
Provider Enumeration Date:
02/11/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  14737 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1518648 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00873632 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com