Provider Demographics
NPI:1548910755
Name:POLK, QUANIQUA
Entity type:Individual
Prefix:
First Name:QUANIQUA
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 1:363 GEORGE BIG REDD CT APT 202
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 MARTIN LUTHER KING JR. DR.
Practice Address - Street 2:432 FL ATKINS BUILDING
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27110
Practice Address - Country:US
Practice Address - Phone:336-750-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCUKU909495074OtherBLUE CROSS BLUE SHIELD TENNESSEE