Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156F00000X | Technician/Technologist | 31002137A | IN |
Y | 225XL0004X | Low Vision | 31002137A | IN |
NPI | 1275600306 |
---|---|
Provider Name | Brenda Kay Polster |
First Address | Bloomington, IN 47405-3603 |
Second Address | Bloomington, IN 47405-3603 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/11/2006 |
Last Update Date | 22/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000584866 | ANTHEM (01) | IN |
200854470 | (05) | IN |