Provider Demographics
NPI:1336184605
Name:LONG, RITA G (CRNA)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:G
Last Name:LONG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:RITA
Other - Middle Name:
Other - Last Name:MAYBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1025 WESTHAVEN BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-4895
Mailing Address - Country:US
Mailing Address - Phone:615-721-5121
Mailing Address - Fax:
Practice Address - Street 1:1025 WESTHAVEN BLVD STE 210
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-4895
Practice Address - Country:US
Practice Address - Phone:615-721-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN118696367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
3635419Medicare ID - Type Unspecified