Provider Demographics
NPI:1629680335
Name:CULVER, MARRISA (APN)
Entity Type:Individual
Prefix:
First Name:MARRISA
Middle Name:
Last Name:CULVER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746720
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6720
Mailing Address - Country:US
Mailing Address - Phone:815-861-4302
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:436 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3210
Practice Address - Country:US
Practice Address - Phone:260-209-7111
Practice Address - Fax:260-222-2835
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28210427A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily