Provider Demographics
NPI:1083135271
Name:POLK, ANGELA (NP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:POLK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 HOSPITAL DR STE 305
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-8030
Mailing Address - Country:US
Mailing Address - Phone:478-338-9200
Mailing Address - Fax:478-741-5631
Practice Address - Street 1:310 HOSPITAL DR STE 305
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217
Practice Address - Country:US
Practice Address - Phone:478-338-9200
Practice Address - Fax:478-741-5631
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN080331363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty