Provider Demographics
NPI:1770879942
Name:POLK, MELISSA A (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:A
Last Name:POLK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:DIROCCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-3494
Mailing Address - Fax:208-381-2566
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-3494
Practice Address - Fax:208-381-2566
Is Sole Proprietor?:No
Enumeration Date:2011-06-25
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP1093A363LF0000X
IDNP-1093A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily