Provider Demographics
NPI:1235714635
Name:POLK, LISA ANN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:POLK
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 1:134 EVERGREEN CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT ROYAL
Mailing Address - State:NJ
Mailing Address - Zip Code:08061-1128
Mailing Address - Country:US
Mailing Address - Phone:856-516-3844
Mailing Address - Fax:
Practice Address - Street 1:134 EVERGREEN CT
Practice Address - Street 2:
Practice Address - City:MOUNT ROYAL
Practice Address - State:NJ
Practice Address - Zip Code:08061-1128
Practice Address - Country:US
Practice Address - Phone:856-516-3844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01117300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily