Provider Demographics
NPI:1982378071
Name:POLK FREEMAN, KIMBERLY J
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:J
Last Name:POLK FREEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:JOANNETTE
Other - Last Name:POLK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2600 HOUMA BLVD APT 116
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-1334
Mailing Address - Country:US
Mailing Address - Phone:504-518-0619
Mailing Address - Fax:
Practice Address - Street 1:2600 HOUMA BLVD APT 116
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-1334
Practice Address - Country:US
Practice Address - Phone:504-518-0619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA002937288172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver