Provider Demographics
NPI:1255841797
Name:ERVIN, LORI ANN
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:ERVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1120
Mailing Address - Street 2:
Mailing Address - City:OWINGSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40360-1120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:632 SLATE AVE
Practice Address - Street 2:
Practice Address - City:OWINGSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40360-2206
Practice Address - Country:US
Practice Address - Phone:606-674-6386
Practice Address - Fax:606-674-3096
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021400363L00000X
WV110523363LF0000X
KY3011494363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily