Provider Demographics
NPI:1487697538
Name:ERVIN, STACEY D (FNP)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:D
Last Name:ERVIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 UTAH ST
Mailing Address - Street 2:
Mailing Address - City:AVERY
Mailing Address - State:TX
Mailing Address - Zip Code:75554-2600
Mailing Address - Country:US
Mailing Address - Phone:903-908-0352
Mailing Address - Fax:903-798-8895
Practice Address - Street 1:3111 MCCANN RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7842
Practice Address - Country:US
Practice Address - Phone:903-753-1212
Practice Address - Fax:214-712-2487
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP113426363LF0000X
TX630620363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ34911Medicare UPIN