Provider Demographics
NPI:1538569199
Name:JERVIS, STACY (FNP-BC, MED, CNRN)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:JERVIS
Suffix:
Gender:F
Credentials:FNP-BC, MED, CNRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 EDGEMONT DR STE 2
Mailing Address - Street 2:
Mailing Address - City:ARKANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67005-3844
Mailing Address - Country:US
Mailing Address - Phone:620-442-7120
Mailing Address - Fax:620-442-7121
Practice Address - Street 1:2508 EDGEMONT DR STE 2
Practice Address - Street 2:
Practice Address - City:ARKANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:67005-3844
Practice Address - Country:US
Practice Address - Phone:620-442-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-01
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-127265-032163WN0800X
KS53-76375-032363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA5478001Medicaid