Healthcare Provider Details

I. General information

NPI: 1104810506
Provider Name (Legal Business Name): KEVIN KIP MARSH FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 E BATTLEFIELD ST
SPRINGFIELD MO
65804-3981
US

IV. Provider business mailing address

371 ROCK COURT DR
MARSHFIELD MO
65706-7402
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 417-942-2018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2003018972
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: