Provider Demographics
NPI:1194704049
Name:POOL, ROBERTA LEE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:LEE
Last Name:POOL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 BRYAN BLVD
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2775
Mailing Address - Country:US
Mailing Address - Phone:606-523-2005
Mailing Address - Fax:606-523-9704
Practice Address - Street 1:140 BRYAN BLVD
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2775
Practice Address - Country:US
Practice Address - Phone:606-523-2005
Practice Address - Fax:606-523-9704
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4101P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000601701OtherANTHEM
KY78010717Medicaid
KY78010717Medicaid