Provider Demographics
NPI:1093228272
Name:OWENS, SONQUANETTA LONG (APN)
Entity Type:Individual
Prefix:
First Name:SONQUANETTA
Middle Name:LONG
Last Name:OWENS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:SONQUANETTA
Other - Middle Name:WYVETT
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:100 BAPTIST MEMORIAL CIR STE 200
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4476
Practice Address - Country:US
Practice Address - Phone:662-513-3246
Practice Address - Fax:662-513-6248
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902397363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner