Provider Demographics
NPI:1962836379
Name:LONG, THERESA ADELE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ADELE
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 1:10099 WEBB RD
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-8450
Mailing Address - Country:US
Mailing Address - Phone:740-583-0772
Mailing Address - Fax:
Practice Address - Street 1:10099 WEBB RD
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-8450
Practice Address - Country:US
Practice Address - Phone:740-583-0772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN089455164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse