Provider Demographics
NPI:1548657117
Name:POLLEY, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:POLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:THIEU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14010 SMOKETOWN RD
Mailing Address - Street 2:SUITE 117
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4722
Mailing Address - Country:US
Mailing Address - Phone:703-580-0181
Mailing Address - Fax:703-897-8763
Practice Address - Street 1:14010 SMOKETOWN RD
Practice Address - Street 2:SUITE 117
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4722
Practice Address - Country:US
Practice Address - Phone:703-580-0181
Practice Address - Fax:703-897-8763
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172535363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily