Provider Demographics
NPI:1063483477
Name:POOLE, TERESA H (RN MSN FNPC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:H
Last Name:POOLE
Suffix:
Gender:F
Credentials:RN MSN FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901
Mailing Address - Country:US
Mailing Address - Phone:304-645-3220
Mailing Address - Fax:304-645-4103
Practice Address - Street 1:400 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901
Practice Address - Country:US
Practice Address - Phone:304-645-3220
Practice Address - Fax:304-645-4103
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35339363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7104006000Medicaid
P05975Medicare UPIN
WV7104006000Medicaid