Provider Demographics
NPI:1487919650
Name:POOLE SMITH, HEATHER (MSAC, LAC, CA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:POOLE SMITH
Suffix:
Gender:F
Credentials:MSAC, LAC, CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8247 DEVEREUX DR
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8227
Mailing Address - Country:US
Mailing Address - Phone:321-292-1844
Mailing Address - Fax:
Practice Address - Street 1:8247 DEVEREUX DR
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-8227
Practice Address - Country:US
Practice Address - Phone:321-292-1844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3668171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist