Healthcare Provider Details

I. General information

NPI: 1720993983
Provider Name (Legal Business Name): TINA LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4208 CHIEFTAN LN
JONESBORO AR
72401-7655
US

IV. Provider business mailing address

4208 CHIEFTAN LN
JONESBORO AR
72401-7655
US

V. Phone/Fax

Practice location:
  • Phone: 870-910-7819
  • Fax: 870-910-6984
Mailing address:
  • Phone: 870-910-7819
  • Fax: 870-910-6984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL051835
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: