Provider Demographics
NPI:1518598127
Name:POLK, RUKIYAH CHANISE (MISC)
Entity Type:Individual
Prefix:
First Name:RUKIYAH
Middle Name:CHANISE
Last Name:POLK
Suffix:
Gender:F
Credentials:MISC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 SUTTON WAY APT 239
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-4190
Mailing Address - Country:US
Mailing Address - Phone:530-786-2617
Mailing Address - Fax:
Practice Address - Street 1:210 SUTTON WAY APT 239
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-4190
Practice Address - Country:US
Practice Address - Phone:530-786-2617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-01
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator