Provider Demographics
NPI:1093838526
Name:POLK, MARIA GWENDOLINE (RN MSN GNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:GWENDOLINE
Last Name:POLK
Suffix:
Gender:F
Credentials:RN MSN GNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 BEECHNUT ST STE 218
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096-1825
Mailing Address - Country:US
Mailing Address - Phone:713-521-0006
Mailing Address - Fax:
Practice Address - Street 1:4660 BEECHNUT ST STE 218-A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-1824
Practice Address - Country:US
Practice Address - Phone:713-521-0006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX425936363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00731415OtherMEDICARE RAILROAD
TXP00784266OtherMEDICARE RAILROAD
TX190358502Medicaid
TX8Y3481OtherBC/BS
TXP00784266OtherMEDICARE RAILROAD
TXP00731415OtherMEDICARE RAILROAD