Provider Demographics
NPI:1912538463
Name:POOLE, TRACY C (NP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:C
Last Name:POOLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:C
Other - Last Name:BRADSHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4196 HIGHWAY 62 412 STE A
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-8002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1308 E PAGE AVE
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4518
Practice Address - Country:US
Practice Address - Phone:501-337-9820
Practice Address - Fax:501-468-0478
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR123708363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology