Provider Demographics
NPI:1639204746
Name:POOLE, SALLY W (NPRN FNP)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:W
Last Name:POOLE
Suffix:
Gender:F
Credentials:NPRN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 OLD SALEM WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9078
Mailing Address - Country:US
Mailing Address - Phone:706-855-5672
Mailing Address - Fax:706-774-5147
Practice Address - Street 1:818 SAINT SEBASTIAN WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2651
Practice Address - Country:US
Practice Address - Phone:706-774-5145
Practice Address - Fax:706-774-5147
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
GARN045012NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily