Basic Information
| Provider Information | |||||||||
| NPI: | 1669712295 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 585 JEWETT RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488548729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176765405 | ||||||||
| FaxNumber: | 5176764560 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 S SAGINAW ST STE 1400 | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485072645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103910662 | ||||||||
| FaxNumber: | 8102398330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2013 | ||||||||
| LastUpdateDate: | 02/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704207893 | MI | Y | Nursing Service Providers | Registered Nurse |
No ID Information.