Provider Demographics
NPI:1114647567
Name:ERVIN, SHALITHA (CNA)
Entity Type:Individual
Prefix:
First Name:SHALITHA
Middle Name:
Last Name:ERVIN
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3127 GREENFIELD RD LOT 271
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-7000
Mailing Address - Country:US
Mailing Address - Phone:601-862-2676
Mailing Address - Fax:
Practice Address - Street 1:3127 GREENFIELD RD LOT 271
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-7000
Practice Address - Country:US
Practice Address - Phone:601-862-2676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS73437376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide