Provider Demographics
NPI:1356933790
Name:LONG, EMILY R (APN)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:R
Last Name:LONG
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:R
Other - Last Name:SISTEK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:420 NE GLEN OAK AVE
Mailing Address - Street 2:STE 401
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3112
Mailing Address - Country:US
Mailing Address - Phone:309-676-8123
Mailing Address - Fax:309-676-8455
Practice Address - Street 1:420 NE GLEN OAK AVE STE 401
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3112
Practice Address - Country:US
Practice Address - Phone:309-676-8123
Practice Address - Fax:309-676-8455
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021894363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty