Provider Demographics
NPI:1114463049
Name:LONG, DYMOND (APN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:DYMOND
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:APN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 N GAY CT
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-1304
Mailing Address - Country:US
Mailing Address - Phone:708-506-6440
Mailing Address - Fax:773-564-3515
Practice Address - Street 1:1715 E 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617
Practice Address - Country:US
Practice Address - Phone:773-768-4437
Practice Address - Fax:773-564-3515
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015381363LF0000X
IL277001290363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily