Provider Demographics
NPI:1174152102
Name:POLK, ALYSSA DIANE (DO)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:DIANE
Last Name:POLK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:DIANE
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:191 THEATER RD
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8679
Practice Address - Country:US
Practice Address - Phone:608-785-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI76237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine