Basic Information
| Provider Information | |||||||||
| NPI: | 1013369206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POOLE | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 589 | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998330589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077724291 | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 FRAM STREET | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077724291 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2016 | ||||||||
| LastUpdateDate: | 09/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 129230 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 018249900 | 05 | FL | MEDICAID |