Healthcare Provider Details

I. General information

NPI: 1053973081
Provider Name (Legal Business Name): HEATHER ELIZABETH POLK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2019
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SOUTHLAND DR
SIKESTON MO
63801-4403
US

IV. Provider business mailing address

6738 STATE HIGHWAY 77
BENTON MO
63736-8238
US

V. Phone/Fax

Practice location:
  • Phone: 573-472-1770
  • Fax: 573-472-4050
Mailing address:
  • Phone: 573-313-2500
  • Fax: 573-313-2500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2019022989
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: