=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962611236
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNE O'NEAL POORE FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 RITTER ST
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-3323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-457-8182
-----------------------------------------------------
Fax | 415-457-3490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 BAYWOOD AVE
-----------------------------------------------------
City | SAN ANSELMO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94960-2509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-457-2586
-----------------------------------------------------
Fax | 415-482-9365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN 418826 NP 8392
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------