Provider Demographics
NPI:1700274313
Name:POLLEY, KRISTINA LUCILLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:LUCILLE
Last Name:POLLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KRISTINA
Other - Middle Name:LUCILLE
Other - Last Name:SANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:444 SW CENTER ST
Mailing Address - Street 2:PO BOX 187
Mailing Address - City:FASION
Mailing Address - State:NC
Mailing Address - Zip Code:28341-2834
Mailing Address - Country:US
Mailing Address - Phone:847-797-0528
Mailing Address - Fax:855-748-6239
Practice Address - Street 1:2409 MURCHISON RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3519
Practice Address - Country:US
Practice Address - Phone:910-488-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant