Provider Demographics
NPI:1609423516
Name:POOLE, KORTIA (LPN)
Entity Type:Individual
Prefix:
First Name:KORTIA
Middle Name:
Last Name:POOLE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4574 ONONDAGA BLVD APT 38
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-3308
Mailing Address - Country:US
Mailing Address - Phone:315-992-3081
Mailing Address - Fax:
Practice Address - Street 1:4574 ONONDAGA BLVD APT 38
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-3308
Practice Address - Country:US
Practice Address - Phone:315-992-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-25
Last Update Date:2019-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335858-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse