Healthcare Provider Details

I. General information

NPI: 1407031453
Provider Name (Legal Business Name): SHAMARA MONIQUE LONG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 05/14/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 W. MOUNTAIN VIEW ST.
ALTA DENA CA
91001
US

IV. Provider business mailing address

760 W. MOUNTAIN VIEW ST.
ALTA DENA CA
91001
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6793
  • Fax:
Mailing address:
  • Phone: 517-879-3209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN 230989
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number95395942
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: