=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487611646
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY CATHERINE POLK N.P.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2006
-----------------------------------------------------
Last Update Date | 05/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1698 MAIN RD
-----------------------------------------------------
City | TIVERTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-472-1103
-----------------------------------------------------
Fax | 800-506-1624
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1698 MAIN RD
-----------------------------------------------------
City | TIVERTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02878-4518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-472-1103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | S52455
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------