Healthcare Provider Details

I. General information

NPI: 1538880778
Provider Name (Legal Business Name): SOPHIE POULIOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/14/2026
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 PLEASANT ST STE 608
DES MOINES IA
50309-1418
US

IV. Provider business mailing address

PO BOX 424
DES MOINES IA
50302-0424
US

V. Phone/Fax

Practice location:
  • Phone: 515-875-9560
  • Fax: 515-875-9561
Mailing address:
  • Phone: 515-875-9255
  • Fax: 515-875-9223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTC076
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberTC076
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number122671
License Number StateIA
# 5
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC076
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: