Provider Demographics
NPI:1194035782
Name:HASKINS, POLLY ANNE (NP-C)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:ANNE
Last Name:HASKINS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 AVENUE OF THE CITIES
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244
Mailing Address - Country:US
Mailing Address - Phone:515-471-9728
Mailing Address - Fax:515-471-9319
Practice Address - Street 1:465 AVENUE OF THE CITIES
Practice Address - Street 2:SUITE 100
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244
Practice Address - Country:US
Practice Address - Phone:309-779-5670
Practice Address - Fax:309-779-5675
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008397363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL813590021Medicare PIN
IL200715011Medicare PIN