Provider Demographics
NPI:1558545780
Name:LONG, BETH R (FNP)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:R
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4022 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358
Mailing Address - Country:US
Mailing Address - Phone:731-686-7004
Mailing Address - Fax:731-686-7078
Practice Address - Street 1:4022 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-3453
Practice Address - Country:US
Practice Address - Phone:731-686-7004
Practice Address - Fax:731-686-7078
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13077363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily