Provider Demographics
NPI:1679647812
Name:POLK, SUSAN GAYLE (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAYLE
Last Name:POLK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:GAYLE
Other - Last Name:HANEGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:412 BROOKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:KS
Mailing Address - Zip Code:66043-1488
Mailing Address - Country:US
Mailing Address - Phone:913-727-5283
Mailing Address - Fax:
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:MUNSON ARMY HEALTH CENTER ATTN MCXN-COD, MS COTTON
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-684-6562
Practice Address - Fax:913-684-6208
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-97418-081163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse