Healthcare Provider Details

I. General information

NPI: 1003371923
Provider Name (Legal Business Name): CULLEN WHICKER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N EDWARD ST
DECATUR IL
62526-4192
US

IV. Provider business mailing address

304 COREY LN
CHAMPAIGN IL
61822-1130
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-2575
  • Fax:
Mailing address:
  • Phone: 217-972-4546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209018652
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: