Provider Demographics
NPI:1669712295
Name:POLK, MARY KAY (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:POLK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 JEWETT RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-8729
Mailing Address - Country:US
Mailing Address - Phone:517-676-5405
Mailing Address - Fax:517-676-4560
Practice Address - Street 1:4400 S SAGINAW ST STE 1400
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2645
Practice Address - Country:US
Practice Address - Phone:810-391-0662
Practice Address - Fax:810-239-8330
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704207893163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse