Provider Demographics
NPI:1710538574
Name:BOONE, POLLY JANE
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:JANE
Last Name:BOONE
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 1:3003 HOLLINS RD NE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-7505
Mailing Address - Country:US
Mailing Address - Phone:540-344-6208
Mailing Address - Fax:540-344-9112
Practice Address - Street 1:3003 HOLLINS RD NE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-7505
Practice Address - Country:US
Practice Address - Phone:540-344-6208
Practice Address - Fax:540-344-9112
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904011171104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker