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General NPI Number Information
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NPI Number | 1720623036
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Entity Type | Individual
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Provider Name | KEVAN MICHAEL POLEY FNP-BC
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Gender | Male
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Dates
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Enumeration Date | 11/11/2019
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Last Update Date | 06/29/2022
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Provider Practice Location Address
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Address Line | 1921 CAPITAL CIR NE
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City | TALLAHASSEE
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State | FL
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Zip | 32308-4492
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Country | US
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Telephone | 850-575-4998
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Fax |
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Provider Business Mailing Address
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Address Line | 1112 S MAGNOLIA DR APT K202
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City | TALLAHASSEE
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State | FL
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Zip | 32301-4681
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Country | US
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Telephone | 850-450-9096
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 11003136
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License Number State | FL
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