Healthcare Provider Details

I. General information

NPI: 1669815122
Provider Name (Legal Business Name): MARVIN KULLEN POE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2013
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N KENTUCKY AVE
WEST PLAINS MO
65775-2029
US

IV. Provider business mailing address

602 OAK PARK BLVD
WEST PLAINS MO
65775-5195
US

V. Phone/Fax

Practice location:
  • Phone: 417-256-9111
  • Fax:
Mailing address:
  • Phone: 870-217-5458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC003121
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR081024
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: