Provider Demographics
NPI:1346586757
Name:ERVIN, STACI LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:LYNN
Last Name:ERVIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 NEBRASKA ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1436
Mailing Address - Country:US
Mailing Address - Phone:712-252-2477
Mailing Address - Fax:712-252-5920
Practice Address - Street 1:1021 NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1436
Practice Address - Country:US
Practice Address - Phone:712-252-2477
Practice Address - Fax:712-252-5920
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111449363LF0000X
IAA110802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE111449OtherLICENSE
IAA110802OtherLICENSE