Healthcare Provider Details

I. General information

NPI: 1972250660
Provider Name (Legal Business Name): KYLIE ERVIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2022
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 MARION PT
PEKIN IL
61554-9416
US

IV. Provider business mailing address

6 MARION PT
PEKIN IL
61554-9416
US

V. Phone/Fax

Practice location:
  • Phone: 907-980-2512
  • Fax:
Mailing address:
  • Phone: 907-980-2512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209028165
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WF0300X
TaxonomyFlight Registered Nurse
License Number041367713
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: