Provider Demographics
NPI:1689778938
Name:LONGORIA-ORTIZ, VIVIANA LAUREN (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:VIVIANA
Middle Name:LAUREN
Last Name:LONGORIA-ORTIZ
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5316 FALLEN LEAF ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-1548
Mailing Address - Country:US
Mailing Address - Phone:817-658-8029
Mailing Address - Fax:
Practice Address - Street 1:1325 PENNSYLVANIA AVE STE 740
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2144
Practice Address - Country:US
Practice Address - Phone:817-250-5435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137387363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1689778938Medicaid