Healthcare Provider Details

I. General information

NPI: 1134064405
Provider Name (Legal Business Name): CORSICA POLK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 N MOUNT JULIET RD
MT JULIET TN
37122-3315
US

IV. Provider business mailing address

1827 HOLTS CT
MURFREESBORO TN
37128-8508
US

V. Phone/Fax

Practice location:
  • Phone: 347-277-1925
  • Fax: 347-277-1925
Mailing address:
  • Phone: 347-277-1925
  • Fax: 347-277-1925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: