Healthcare Provider Details

I. General information

NPI: 1720623036
Provider Name (Legal Business Name): KEVAN MICHAEL POLEY FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 CAPITAL CIR NE
TALLAHASSEE FL
32308-4492
US

IV. Provider business mailing address

1112 S MAGNOLIA DR APT K202
TALLAHASSEE FL
32301-4681
US

V. Phone/Fax

Practice location:
  • Phone: 850-575-4998
  • Fax:
Mailing address:
  • Phone: 850-450-9096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number11003136
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: