Provider Demographics
NPI:1003456609
Name:LONG, WANDA K (ACNP-BC)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:K
Last Name:LONG
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40891 BREEZY PASS RD
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-7263
Mailing Address - Country:US
Mailing Address - Phone:757-714-0916
Mailing Address - Fax:
Practice Address - Street 1:40891 BREEZY PASS RD
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-7263
Practice Address - Country:US
Practice Address - Phone:757-714-0916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013493363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care