Provider Demographics
NPI:1114515962
Name:KING, POLLY A
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:A
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35064-0221
Mailing Address - Country:US
Mailing Address - Phone:205-253-6819
Mailing Address - Fax:
Practice Address - Street 1:5600 ROCK MOUNTAIN LAKE RD
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35022-8101
Practice Address - Country:US
Practice Address - Phone:205-253-6819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education