Provider Demographics
NPI:1568116010
Name:DUFFUS, POLLY
Entity Type:Individual
Prefix:MRS
First Name:POLLY
Middle Name:
Last Name:DUFFUS
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 1:4420 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313-3521
Mailing Address - Country:US
Mailing Address - Phone:754-214-3169
Mailing Address - Fax:
Practice Address - Street 1:4420 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33313-3521
Practice Address - Country:US
Practice Address - Phone:754-214-3169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10-2752GH251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22444710Medicaid