Provider Demographics
NPI:1326567553
Name:POLK, SHANTELL MONIQUE (MA)
Entity Type:Individual
Prefix:MS
First Name:SHANTELL
Middle Name:MONIQUE
Last Name:POLK
Suffix:
Gender:F
Credentials:MA
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 213093
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91921-3093
Mailing Address - Country:US
Mailing Address - Phone:888-417-5163
Mailing Address - Fax:
Practice Address - Street 1:719 W 58TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-4033
Practice Address - Country:US
Practice Address - Phone:951-230-6728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide