Provider Demographics
NPI:1588106397
Name:POLK, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:POLK
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 1:63 ACORN DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-3043
Mailing Address - Country:US
Mailing Address - Phone:678-515-1844
Mailing Address - Fax:678-515-1843
Practice Address - Street 1:63 ACORN DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-3043
Practice Address - Country:US
Practice Address - Phone:678-515-1844
Practice Address - Fax:678-515-1843
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care