Provider Demographics
NPI:1952607046
Name:POLK, BRANDI MICHELLE
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:MICHELLE
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 1:7051 CYPRESS TERR.
Mailing Address - Street 2:#106
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-8801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7051 CYPRESS TERR.
Practice Address - Street 2:#106
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-8801
Practice Address - Country:US
Practice Address - Phone:239-590-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA53699225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist