Provider Demographics
NPI:1053957423
Name:POLK, CLARA
Entity type:Individual
Prefix:
First Name:CLARA
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 1:1409 WASHINGTON AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1936
Mailing Address - Country:US
Mailing Address - Phone:314-728-1555
Mailing Address - Fax:
Practice Address - Street 1:1409 WASHINGTON AVE STE 204
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1936
Practice Address - Country:US
Practice Address - Phone:314-728-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty