Provider Demographics
NPI:1518339183
Name:POLANCO, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:POLANCO
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 1:1285 VALIANT AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34608-6041
Mailing Address - Country:US
Mailing Address - Phone:352-610-2360
Mailing Address - Fax:
Practice Address - Street 1:1285 VALIANT AVE
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-6041
Practice Address - Country:US
Practice Address - Phone:352-610-2360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906787251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL311215199Medicaid