Healthcare Provider Details

I. General information

NPI: 1962521617
Provider Name (Legal Business Name): GARY L. POOLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 CHURCH ST
STAMPS AR
71860-2816
US

IV. Provider business mailing address

218 CHURCH ST
STAMPS AR
71860-2816
US

V. Phone/Fax

Practice location:
  • Phone: 870-533-8808
  • Fax: 870-533-8838
Mailing address:
  • Phone: 870-533-8808
  • Fax: 870-533-8838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAO1177
License Number StateAR

VIII. Authorized Official

Name: MR. GARY L. POOLE
Title or Position: OWNER
Credential: APN
Phone: 870-533-8808