Provider Demographics
NPI:1497215743
Name:LONG, CHERITA
Entity Type:Individual
Prefix:
First Name:CHERITA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7072
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-7072
Mailing Address - Country:US
Mailing Address - Phone:317-656-7090
Mailing Address - Fax:
Practice Address - Street 1:8555 CEDAR PLACE DR STE 112
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-2344
Practice Address - Country:US
Practice Address - Phone:317-750-5189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist