Provider Demographics
NPI:1710404074
Name:POLK, KIRA
Entity Type:Individual
Prefix:
First Name:KIRA
Middle Name:
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:P.O. BOX 528
Mailing Address - Street 2:ATTN: BH DD SERVICES
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559
Mailing Address - Country:US
Mailing Address - Phone:907-543-2762
Mailing Address - Fax:907-543-3152
Practice Address - Street 1:460 RIDGECREST DRIVE
Practice Address - Street 2:SUITE 215
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-2762
Practice Address - Fax:907-543-3152
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1002447Medicaid
AK1004541Medicaid