Healthcare Provider Details

I. General information

NPI: 1922256437
Provider Name (Legal Business Name): JACKIE POLK LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 1ST ST S
WINTER HAVEN FL
33880-3904
US

IV. Provider business mailing address

1201 1ST ST S
WINTER HAVEN FL
33880-3904
US

V. Phone/Fax

Practice location:
  • Phone: 863-297-1702
  • Fax: 863-291-6755
Mailing address:
  • Phone: 863-297-1702
  • Fax: 863-291-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN340111
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: