Provider Demographics
NPI:1932543683
Name:POLK, SHANITA LASHAWN
Entity type:Individual
Prefix:
First Name:SHANITA
Middle Name:LASHAWN
Last Name:POLK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANITA
Other - Middle Name:LASHAWN
Other - Last Name:SUMMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MACBS
Mailing Address - Street 1:3411 SUMAC RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-3336
Mailing Address - Country:US
Mailing Address - Phone:502-572-5058
Mailing Address - Fax:
Practice Address - Street 1:3411 SUMAC RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-3336
Practice Address - Country:US
Practice Address - Phone:502-572-5058
Practice Address - Fax:502-614-5739
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017585291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory