Provider Demographics
NPI:1396824124
Name:POLK THOMAS, ELIZABETH (FNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:POLK THOMAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-9302
Mailing Address - Country:US
Mailing Address - Phone:662-563-7681
Mailing Address - Fax:662-563-7690
Practice Address - Street 1:107 EUREKA ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-2533
Practice Address - Country:US
Practice Address - Phone:662-563-7681
Practice Address - Fax:662-563-7690
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR811462363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0118901Medicaid
MSS47477Medicare UPIN