1881157147 NPI number — MS. KIRSTIN MIR POLING OT

Table of content: CHARMAINE ANN ENERIO APRN-CNP (NPI 1023610458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881157147 NPI number — MS. KIRSTIN MIR POLING OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLING
Provider First Name:
KIRSTIN
Provider Middle Name:
MIR
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KENNEDY
Provider Other First Name:
KIRSTIN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881157147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6962 MAPLE GLEN AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44720-9412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-495-0527
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 CLEVELAND AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44709-3306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-456-0004
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2019

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: 225X00000X , with the licence number:  OT-04441 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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