Healthcare Provider Details

I. General information

NPI: 1396198321
Provider Name (Legal Business Name): POLLY BALTES CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S STANFIELD RD STE A
TROY OH
45373
US

IV. Provider business mailing address

700 S STANFIELD RD STE A
TROY OH
45373-2569
US

V. Phone/Fax

Practice location:
  • Phone: 937-339-5355
  • Fax: 937-339-3056
Mailing address:
  • Phone: 937-339-5355
  • Fax: 937-339-3056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.19230
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: