Healthcare Provider Details

I. General information

NPI: 1023691334
Provider Name (Legal Business Name): SUSAN LONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 E SOUTH ST STE 308
LAKEWOOD CA
90805-4598
US

IV. Provider business mailing address

3300 E SOUTH ST STE 308
LAKEWOOD CA
90805-4598
US

V. Phone/Fax

Practice location:
  • Phone: 562-630-3111
  • Fax:
Mailing address:
  • Phone: 562-630-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95015362
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: