Provider Demographics
NPI:1558385179
Name:WORTHINGTON, POLLY ANN
Entity Type:Individual
Prefix:MS
First Name:POLLY
Middle Name:ANN
Last Name:WORTHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 N.W. MADISON STREET
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055
Mailing Address - Country:US
Mailing Address - Phone:386-755-2307
Mailing Address - Fax:386-754-2377
Practice Address - Street 1:124 NW MADISON ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3922
Practice Address - Country:US
Practice Address - Phone:386-755-2307
Practice Address - Fax:386-754-2377
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA37467225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist