Healthcare Provider Details

I. General information

NPI: 1922363290
Provider Name (Legal Business Name): DIANA ELIZABETH POOLE RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9035 MAIN ST
WOLF LAKE IL
62998-1057
US

IV. Provider business mailing address

9035 MAIN ST
WOLF LAKE IL
62998-1057
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-8260
  • Fax:
Mailing address:
  • Phone: 618-833-8260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279G1100X
TaxonomyGeneral Care Registered Respiratory Therapist
License Number194007005
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: