Provider Demographics
NPI:1033395504
Name:POE, JESSICA LANAE (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LANAE
Last Name:POE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E PECAN ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-6141
Mailing Address - Country:US
Mailing Address - Phone:580-379-5000
Mailing Address - Fax:580-379-5509
Practice Address - Street 1:1200 E PECAN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-6141
Practice Address - Country:US
Practice Address - Phone:803-795-8605
Practice Address - Fax:580-379-5859
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK89966367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200131810AMedicaid