Healthcare Provider Details

I. General information

NPI: 1417774100
Provider Name (Legal Business Name): TYREKE POOLE RN, SNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4494 PALMER RD N
BETHESDA MD
20814
US

IV. Provider business mailing address

19420 RIDGECREST DR
GERMANTOWN MD
20874-1539
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4830
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number26NR18600700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: