Provider Demographics
NPI:1881033439
Name:ERVIN, NICOLE M (ARNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ERVIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BAXTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1110 SE ALDER STREET #301
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:541-530-2793
Mailing Address - Fax:206-385-7376
Practice Address - Street 1:1110 SE ALDER STREET #301
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:971-328-1565
Practice Address - Fax:206-385-7376
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201350111NP363LF0000X
WAAP60579125363LP0808X
OR202006403NP-PP363LP0808X
WARN60568890163WP0808X
OR201341028RN363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1881033439Medicaid