Provider Demographics
NPI:1497274963
Name:LONG, DANA DIANE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:DIANE
Last Name:LONG
Suffix:
Gender:F
Credentials:PMHNP-BC
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 121
Mailing Address - Street 2:
Mailing Address - City:RUSK
Mailing Address - State:TX
Mailing Address - Zip Code:75785-0121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 MEADOWLARK LN
Practice Address - Street 2:
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785-3693
Practice Address - Country:US
Practice Address - Phone:903-721-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135323363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health