Provider Demographics
NPI:1497022081
Name:KIRK, MARVELETTA
Entity Type:Individual
Prefix:
First Name:MARVELETTA
Middle Name:
Last Name:KIRK
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 1:6530 ANNIE OAKLEY DR
Mailing Address - Street 2:512
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6530 ANNIE OAKLEY DR
Practice Address - Street 2:512
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2167
Practice Address - Country:US
Practice Address - Phone:702-239-6125
Practice Address - Fax:702-825-4873
Is Sole Proprietor?:No
Enumeration Date:2011-11-26
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV20111675665Medicaid