1700274313 NPI number — MRS. KRISTINA LUCILLE POLLEY PA-C

Table of content: MRS. KRISTINA LUCILLE POLLEY PA-C (NPI 1700274313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700274313 NPI number — MRS. KRISTINA LUCILLE POLLEY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLLEY
Provider First Name:
KRISTINA
Provider Middle Name:
LUCILLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SANDERS
Provider Other First Name:
KRISTINA
Provider Other Middle Name:
LUCILLE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700274313
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
444 SW CENTER ST
Provider Second Line Business Mailing Address:
PO BOX 187
Provider Business Mailing Address City Name:
FASION
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28341-2834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-797-0528
Provider Business Mailing Address Fax Number:
855-748-6239

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2409 MURCHISON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28301-3519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-488-4525
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/05/2015

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: 363A00000X , with the licence number:  0010-05418 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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