Provider Demographics
NPI:1578534970
Name:LONG, STEPHANIE SUE (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SUE
Last Name:LONG
Suffix:
Gender:F
Credentials:CRNA
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 1351
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-1351
Mailing Address - Country:US
Mailing Address - Phone:800-235-1415
Mailing Address - Fax:913-234-1108
Practice Address - Street 1:1808 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2724
Practice Address - Country:US
Practice Address - Phone:479-968-2841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCTP161367500000X
ARC01566367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR771014101OtherAR BREASTCARE
P00377263OtherRR MEDICARE GROUP #CC5970
AR5Y760OtherBCBS OF AR
AR160268001Medicaid
AR5Y7607607Medicare PIN