Provider Demographics
NPI:1629800602
Name:POLK, CHARLEA MONEE
Entity type:Individual
Prefix:
First Name:CHARLEA
Middle Name:MONEE
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 1:215 LONGFELLOW DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-2512
Mailing Address - Country:US
Mailing Address - Phone:719-358-0293
Mailing Address - Fax:
Practice Address - Street 1:5040 CORPORATE PLAZA DR STE 7G
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-6100
Practice Address - Country:US
Practice Address - Phone:719-249-7896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-17
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program