Provider Demographics
NPI:1972250660
Name:ERVIN, KYLIE (RN)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:ERVIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MARION PT
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-9416
Mailing Address - Country:US
Mailing Address - Phone:907-980-2512
Mailing Address - Fax:
Practice Address - Street 1:6 MARION PT
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-9416
Practice Address - Country:US
Practice Address - Phone:907-980-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041367713163WF0300X
IL209028165363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WF0300XNursing Service ProvidersRegistered NurseFlightGroup - Single Specialty