Provider Demographics
NPI:1629662812
Name:POOLE, CLARISSA JANELLE
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:JANELLE
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 1:11600 BOARDWALK AVE NE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-8127
Mailing Address - Country:US
Mailing Address - Phone:240-362-4146
Mailing Address - Fax:
Practice Address - Street 1:11600 BOARDWALK AVE NE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-8127
Practice Address - Country:US
Practice Address - Phone:240-362-4146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV860563747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant