Provider Demographics
NPI:1952855272
Name:POOLE, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
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:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0310
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-342-2193
Practice Address - Street 1:1001 BOULDERS PKWY STE 110
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-5513
Practice Address - Country:US
Practice Address - Phone:804-410-9749
Practice Address - Fax:804-272-3498
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173812363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06115OtherGROUP PTAN