Provider Demographics
NPI:1669815122
Name:POE, MARVIN KULLEN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:KULLEN
Last Name:POE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-5195
Mailing Address - Country:US
Mailing Address - Phone:870-217-5458
Mailing Address - Fax:
Practice Address - Street 1:1100 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2029
Practice Address - Country:US
Practice Address - Phone:417-256-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-14
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR081024163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse