Provider Demographics
NPI:1912538463
Name:POOLE, TRACY C (NP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:C
Last Name:POOLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:C
Other - Last Name:BRADSHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1509 DULLES DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3718
Mailing Address - Country:US
Mailing Address - Phone:337-991-9276
Mailing Address - Fax:337-943-0846
Practice Address - Street 1:609 SW 8TH ST FL 6
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-7886
Practice Address - Country:US
Practice Address - Phone:337-991-9276
Practice Address - Fax:337-943-0846
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR123708363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology