Provider Demographics
NPI:1841252426
Name:POOLE, LAUREL MELISSA (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:MELISSA
Last Name:POOLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:MELISSA
Other - Last Name:WHITMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:820 SPRINGER DR
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6413
Mailing Address - Country:US
Mailing Address - Phone:815-744-8554
Mailing Address - Fax:630-495-1770
Practice Address - Street 1:1124 ESSINGTON RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8423
Practice Address - Country:US
Practice Address - Phone:815-744-8554
Practice Address - Fax:815-744-3969
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004274363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ41528Medicare UPIN
GA97WCGLMMedicare ID - Type Unspecified