Provider Demographics
NPI:1669269502
Name:POOLE, QUERITA
Entity type:Individual
Prefix:
First Name:QUERITA
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 1:25724 GRAYSON LNDG
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35756-5076
Mailing Address - Country:US
Mailing Address - Phone:615-484-1551
Mailing Address - Fax:615-484-1551
Practice Address - Street 1:25724 GRAYSON LNDG
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35756-5076
Practice Address - Country:US
Practice Address - Phone:615-484-1551
Practice Address - Fax:615-484-1551
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10961758172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver