Provider Demographics
NPI:1013131127
Name:POOLE, LISA GRAY (CNM)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GRAY
Last Name:POOLE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO DRAWER 12610
Mailing Address - Street 2:2818 NEUSE BLVD
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562
Mailing Address - Country:US
Mailing Address - Phone:252-636-4920
Mailing Address - Fax:252-636-4970
Practice Address - Street 1:2818 NEUSE BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562
Practice Address - Country:US
Practice Address - Phone:252-636-4920
Practice Address - Fax:252-636-4970
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12177176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCZM0000024OtherNC PHARMACY BOARD
NC383OtherNC CNM