Provider Demographics
NPI:1700392016
Name:LONG, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
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 1:406 HALKIES ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77587-3725
Mailing Address - Country:US
Mailing Address - Phone:281-851-7203
Mailing Address - Fax:
Practice Address - Street 1:3332 PLAINVIEW ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-1906
Practice Address - Country:US
Practice Address - Phone:832-649-2073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX134881363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner