Provider Demographics
NPI:1316710908
Name:ERVIN, SUSAN RENE'
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:RENE'
Last Name:ERVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:RENE'
Other - Last Name:HECTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:18231 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-6925
Mailing Address - Country:US
Mailing Address - Phone:402-657-9544
Mailing Address - Fax:
Practice Address - Street 1:9239 W CENTER RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-1933
Practice Address - Country:US
Practice Address - Phone:402-399-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE34604163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse