Provider Demographics
NPI:1285040618
Name:POLANCO, PAOLA
Entity Type:Individual
Prefix:
First Name:PAOLA
Middle Name:
Last Name:POLANCO
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 1:675 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2635
Mailing Address - Country:US
Mailing Address - Phone:706-546-5526
Mailing Address - Fax:706-546-5687
Practice Address - Street 1:675 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601
Practice Address - Country:US
Practice Address - Phone:706-546-5526
Practice Address - Fax:706-546-5687
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR31232R174400000X
GA75818174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist