Healthcare Provider Details

I. General information

NPI: 1629680335
Provider Name (Legal Business Name): MARRISA CULVER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 E WASHINGTON BLVD
FORT WAYNE IN
46802-3210
US

IV. Provider business mailing address

PO BOX 746720
ATLANTA GA
30374-6720
US

V. Phone/Fax

Practice location:
  • Phone: 260-209-7111
  • Fax: 260-222-2835
Mailing address:
  • Phone: 815-861-4302
  • Fax: 773-866-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28210427A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: