Provider Demographics
NPI:1447577820
Name:POLACHEK, BRENDA L (FNP-BC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:POLACHEK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 N BELT HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-1299
Mailing Address - Country:US
Mailing Address - Phone:816-749-4444
Mailing Address - Fax:816-749-4446
Practice Address - Street 1:4201 N BELT HWY
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-1299
Practice Address - Country:US
Practice Address - Phone:816-749-4444
Practice Address - Fax:816-749-4446
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO134300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1447577820Medicaid
KS200658140AMedicaid
MOP00847182OtherRR MEDICARE
MOP00847182OtherRR MEDICARE