Provider Demographics
NPI:1902259104
Name:POOLE, MICHELLE CRISTINE
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:CRISTINE
Last Name:POOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 S MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3973
Mailing Address - Country:US
Mailing Address - Phone:573-247-4413
Mailing Address - Fax:
Practice Address - Street 1:1656 E 12TH ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-4004
Practice Address - Country:US
Practice Address - Phone:307-577-5718
Practice Address - Fax:301-577-5716
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator