Provider Demographics
NPI:1073708434
Name:POOL, LISA A (CNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:POOL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:935 E SNYDER AVE
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:OH
Practice Address - Zip Code:43543-1251
Practice Address - Country:US
Practice Address - Phone:419-485-3106
Practice Address - Fax:419-485-8776
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.09564363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH24611Medicare PIN
OH24612Medicare PIN