Provider Demographics
NPI:1417326547
Name:POLLY, MIKA (FNP)
Entity Type:Individual
Prefix:
First Name:MIKA
Middle Name:
Last Name:POLLY
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 1:4802 N LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3025
Mailing Address - Country:US
Mailing Address - Phone:806-788-0040
Mailing Address - Fax:806-788-0015
Practice Address - Street 1:4642 N LOOP 289
Practice Address - Street 2:STE 211
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-2425
Practice Address - Country:US
Practice Address - Phone:806-712-9007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129050363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily