Provider Demographics
NPI:1003231689
Name:ERVIN, STACY (APN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ERVIN
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 WASHINGTON ST FL 14
Mailing Address - Street 2:EIGHT TOWER BRIDGE, SUITE 1400
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2083
Mailing Address - Country:US
Mailing Address - Phone:866-825-3227
Mailing Address - Fax:
Practice Address - Street 1:401 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4255
Practice Address - Country:US
Practice Address - Phone:866-825-3227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011244363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily