Provider Demographics
NPI:1285108381
Name:POLISAR, MELISSA (CRNA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:POLISAR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 LAKELAND HILLS BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3019
Mailing Address - Country:US
Mailing Address - Phone:863-680-7830
Mailing Address - Fax:866-264-8519
Practice Address - Street 1:1600 LAKELAND HILLS BLVD.
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3019
Practice Address - Country:US
Practice Address - Phone:863-680-7830
Practice Address - Fax:866-264-8519
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9432464163W00000X
FL11001042367500000X
FLAPRN11001042367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse