1124801667 NPI number — BRIANNA DANAE POLKA FNP

Table of content: BRIANNA DANAE POLKA FNP (NPI 1124801667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124801667 NPI number — BRIANNA DANAE POLKA FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLKA
Provider First Name:
BRIANNA
Provider Middle Name:
DANAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POLKA-GOODMAN
Provider Other First Name:
BRIANNA
Provider Other Middle Name:
DANAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124801667
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
480 E JEFFERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUTLER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16001-4780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-282-1530
Provider Business Mailing Address Fax Number:
724-282-1451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
480 E JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUTLER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16001-4780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-282-1530
Provider Business Practice Location Address Fax Number:
724-282-1451
Provider Enumeration Date:
08/17/2023

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:  SP027814 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: SP027814 . This is a "PA NP LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".