Provider Demographics
NPI:1053973081
Name:POLK, HEATHER ELIZABETH (APRN)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ELIZABETH
Last Name:POLK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6738 STATE HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63736-8238
Mailing Address - Country:US
Mailing Address - Phone:573-313-2500
Mailing Address - Fax:573-313-2500
Practice Address - Street 1:200 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4403
Practice Address - Country:US
Practice Address - Phone:573-472-1770
Practice Address - Fax:573-472-4050
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-29
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019022989363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420077159Medicaid
MO2019022989OtherMISSOURI STATE BOARD OF NURSING