Provider Demographics
NPI:1477802254
Name:LONG, ELLEN ADELE (LPN)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:ADELE
Last Name:LONG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3828 LONGVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16510-3530
Mailing Address - Country:US
Mailing Address - Phone:814-528-7046
Mailing Address - Fax:
Practice Address - Street 1:3828 LONGVIEW AVE
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16510-3530
Practice Address - Country:US
Practice Address - Phone:814-528-7046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN277282164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse