Basic Information
| Provider Information | |||||||||
| NPI: | 1922022839 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POOLE | ||||||||
| FirstName: | KIMBERLIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 MAIN ST | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | CORTLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130456606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077533797 | ||||||||
| FaxNumber: | 6077536677 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 CENTRAL ST | ||||||||
| Address2: | |||||||||
| City: | MORAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131183427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154979066 | ||||||||
| FaxNumber: | 3154973836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 01/19/2012 | ||||||||
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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 | 363L00000X | F333065-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 02639201 | 05 | NY | MEDICAID |