Provider Demographics
NPI:1952953689
Name:POOLE, MARLA GWEN (APRN)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:GWEN
Last Name:POOLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:760 26TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6799
Mailing Address - Country:US
Mailing Address - Phone:229-985-1457
Mailing Address - Fax:229-890-9430
Practice Address - Street 1:760 26TH AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6799
Practice Address - Country:US
Practice Address - Phone:229-985-1457
Practice Address - Fax:229-890-9430
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN326199363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner