Provider Demographics
NPI:1912172180
Name:EARVIN, MARILYN R (ANP)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:R
Last Name:EARVIN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-9123
Mailing Address - Fax:314-747-3338
Practice Address - Street 1:400 S KINGSHIGHWAY BLVD
Practice Address - Street 2:DEPT EMERGENCY MED
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1014
Practice Address - Country:US
Practice Address - Phone:314-362-9123
Practice Address - Fax:314-747-3338
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO122785363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420687725Medicaid
ILENROLLEDMedicaid