Healthcare Provider Details

I. General information

NPI: 1093456436
Provider Name (Legal Business Name): POLLY DE MILLE RN, ACSM-CEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 E 72ND ST
NEW YORK NY
10021-4099
US

IV. Provider business mailing address

535 W 110TH ST APT 12F
NEW YORK NY
10025-2071
US

V. Phone/Fax

Practice location:
  • Phone: 646-797-8005
  • Fax:
Mailing address:
  • Phone: 917-319-5286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: