Provider Demographics
NPI:1023843711
Name:POLK, SHAMBRIAE LA'TRICE
Entity type:Individual
Prefix:
First Name:SHAMBRIAE
Middle Name:LA'TRICE
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 1:8619 RUSTOWN DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-4757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8619 RUSTOWN DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-4757
Practice Address - Country:US
Practice Address - Phone:469-585-2547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA18741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program