Healthcare Provider Details

I. General information

NPI: 1932898210
Provider Name (Legal Business Name): MARSHALL KEAVIN HULETT FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 S MAIN ST
BAXLEY GA
31513-0104
US

IV. Provider business mailing address

388 S MAIN ST
BAXLEY GA
31513-0104
US

V. Phone/Fax

Practice location:
  • Phone: 912-705-9680
  • Fax: 912-705-0531
Mailing address:
  • Phone: 912-705-9680
  • Fax: 912-705-0531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN259642
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: