Provider Demographics
NPI:1881361913
Name:POOLE, ILISSA NICOLE
Entity type:Individual
Prefix:
First Name:ILISSA
Middle Name:NICOLE
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 1:1124 SUNSET TER
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-1041
Mailing Address - Country:US
Mailing Address - Phone:304-942-9941
Mailing Address - Fax:
Practice Address - Street 1:1124 SUNSET TER
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WV
Practice Address - Zip Code:25541-1041
Practice Address - Country:US
Practice Address - Phone:304-942-9941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant