Provider Demographics
NPI:1992113708
Name:POOLE, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:POOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:SCISSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12420 MILESTONE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-7111
Mailing Address - Country:US
Mailing Address - Phone:240-686-2300
Mailing Address - Fax:
Practice Address - Street 1:20010 CENTURY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-1115
Practice Address - Country:US
Practice Address - Phone:240-686-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005430363A00000X
VA0110005737363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant