Provider Demographics
NPI:1407587751
Name:POOLE, AKEISTA MARIE
Entity Type:Individual
Prefix:
First Name:AKEISTA
Middle Name:MARIE
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 1:9226 GRANDVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-1722
Mailing Address - Country:US
Mailing Address - Phone:734-621-1152
Mailing Address - Fax:
Practice Address - Street 1:9226 GRANDVILLE AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-1722
Practice Address - Country:US
Practice Address - Phone:734-621-1152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI00000999251E00000X
MIMI000009996251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health