Provider Demographics
NPI:1578031480
Name:POLK, ALYSHA MARIE
Entity Type:Individual
Prefix:
First Name:ALYSHA
Middle Name:MARIE
Last Name:POLK
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 1:1274 BEE ST N
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7375
Mailing Address - Country:US
Mailing Address - Phone:904-207-8773
Mailing Address - Fax:
Practice Address - Street 1:1274 BEE ST N
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7375
Practice Address - Country:US
Practice Address - Phone:904-207-8773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28863225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant