Provider Demographics
NPI:1922022839
Name:POOLE, KIMBERLIE (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLIE
Middle Name:
Last Name:POOLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MAIN ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-6606
Mailing Address - Country:US
Mailing Address - Phone:607-753-3797
Mailing Address - Fax:607-753-6677
Practice Address - Street 1:23 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:MORAVIA
Practice Address - State:NY
Practice Address - Zip Code:13118-3427
Practice Address - Country:US
Practice Address - Phone:315-497-9066
Practice Address - Fax:315-497-3836
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333065-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02639201Medicaid
NYCC3443Medicare ID - Type Unspecified
NY02639201Medicaid