Healthcare Provider Details

I. General information

NPI: 1083135271
Provider Name (Legal Business Name): ANGELA POLK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 04/07/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MARTIN LUTHER KING JR BLVD
MACON GA
31201-3490
US

IV. Provider business mailing address

250 MARTIN LUTHER KING JR BLVD
MACON GA
31201-3490
US

V. Phone/Fax

Practice location:
  • Phone: 478-301-4111
  • Fax: 478-301-5812
Mailing address:
  • Phone: 478-301-4111
  • Fax: 478-301-5812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN080331
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: