Healthcare Provider Details

I. General information

NPI: 1366065104
Provider Name (Legal Business Name): STACEY ANN POOLE DNP, RN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 RISEN STAR DR
CRESTVIEW FL
32539-6071
US

IV. Provider business mailing address

521 RISEN STAR DR
CRESTVIEW FL
32539-6071
US

V. Phone/Fax

Practice location:
  • Phone: 480-608-5157
  • Fax:
Mailing address:
  • Phone: 480-808-9505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9559718
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number245674
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP145602
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11012113
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: