Provider Demographics
NPI:1104102276
Name:POLSTON, REBECCA ROSS ELIZABETH
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ROSS ELIZABETH
Last Name:POLSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3201
Mailing Address - Country:US
Mailing Address - Phone:612-963-7770
Mailing Address - Fax:
Practice Address - Street 1:3135 2ND AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3201
Practice Address - Country:US
Practice Address - Phone:612-963-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No174N00000XOther Service ProvidersLactation Consultant, Non-RN