1932543683 NPI number — SHANITA LASHAWN POLK

Table of content: SHANITA LASHAWN POLK (NPI 1932543683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932543683 NPI number — SHANITA LASHAWN POLK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLK
Provider First Name:
SHANITA
Provider Middle Name:
LASHAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUMMERS
Provider Other First Name:
SHANITA
Provider Other Middle Name:
LASHAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MACBS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1932543683
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3411 SUMAC RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40216-3336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-572-5058
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3411 SUMAC RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40216-3336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-572-5058
Provider Business Practice Location Address Fax Number:
502-614-5739
Provider Enumeration Date:
04/24/2013

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: 291U00000X , with the licence number:  017585 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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