Provider Demographics
NPI:1346882974
Name:POLAK, RACHAEL MARIE (ACNP)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:MARIE
Last Name:POLAK
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1305
Mailing Address - Fax:937-522-7513
Practice Address - Street 1:405 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-7538
Practice Address - Country:US
Practice Address - Phone:937-723-3841
Practice Address - Fax:937-723-4209
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX856862363LA2100X
OHAPRN.CNP.0031107363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care