Provider Demographics
NPI:1346375433
Name:POE, LAURA LEE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:LEE
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:PO BOX 770086
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38177-0086
Mailing Address - Country:US
Mailing Address - Phone:901-482-1677
Mailing Address - Fax:731-764-6696
Practice Address - Street 1:825 RIDGE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9411
Practice Address - Country:US
Practice Address - Phone:901-685-6150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN094199163W00000X
TNAPN 11374163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3731062Medicaid
TN3731062Medicaid