Healthcare Provider Details

I. General information

NPI: 1356206650
Provider Name (Legal Business Name): MARSHALL POULIN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ARRICOLA AVE
ST AUGUSTINE FL
32080-4515
US

IV. Provider business mailing address

2460 OLD MOULTRIE RD STE 1
ST AUGUSTINE FL
32086-4198
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-4368
  • Fax:
Mailing address:
  • Phone: 904-825-4368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11047813
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRN.1641150
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: