1134156318 NPI number — ELIZABETH M. LONG APRN-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134156318 NPI number — ELIZABETH M. LONG APRN-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONG
Provider First Name:
ELIZABETH
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134156318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7945 GLENEAGLES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAUMONT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77707-5466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-840-4999
Provider Business Mailing Address Fax Number:
409-983-5146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
755 N 11TH ST
Provider Second Line Business Practice Location Address:
SUITE P-5200
Provider Business Practice Location Address City Name:
BEAUMONT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77702-1500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-898-2994
Provider Business Practice Location Address Fax Number:
409-983-5146
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  537565 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 183748601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 537565 . This is a "APRN-C LICENSE #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 183746001 . This is a "MEDICAID GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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