Provider Demographics
NPI:1013369206
Name:POOLE, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:POOLE
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:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833-0589
Mailing Address - Country:US
Mailing Address - Phone:907-772-4291
Mailing Address - Fax:
Practice Address - Street 1:103 FRAM STREET
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833
Practice Address - Country:US
Practice Address - Phone:907-772-4291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK129230363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018249900Medicaid