Provider Demographics
NPI:1508286212
Name:ERVIN, TRACY S
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:S
Last Name:ERVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:S
Other - Last Name:ERVIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:388 SW 62ND BLVD APT 7
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2050
Mailing Address - Country:US
Mailing Address - Phone:740-334-7385
Mailing Address - Fax:
Practice Address - Street 1:580 W 8TH ST
Practice Address - Street 2:BOX T-11
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6533
Practice Address - Country:US
Practice Address - Phone:904-244-3990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9328203363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014760900Medicaid
FL012180900Medicaid
GA003151484AMedicaid
FLP01444903Medicare PIN
FL014760900Medicaid