Provider Demographics
NPI:1730664277
Name:POLIVKA, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:POLIVKA
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 1:140 LOWER BORONDO
Mailing Address - Street 2:
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-3079
Mailing Address - Country:US
Mailing Address - Phone:832-863-1668
Mailing Address - Fax:
Practice Address - Street 1:140 LOWER BORONDO
Practice Address - Street 2:
Practice Address - City:LA MARQUE
Practice Address - State:TX
Practice Address - Zip Code:77568-3079
Practice Address - Country:US
Practice Address - Phone:832-863-1668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX751211163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse