Healthcare Provider Details

I. General information

NPI: 1124497987
Provider Name (Legal Business Name): EVONNE MARIE LONG AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EVONNE MARIE CLEVELAND AUD

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N DAVIS ST STE 101
JACKSONVILLE FL
32209
US

IV. Provider business mailing address

1010 N DAVIS ST STE 101
JACKSONVILLE FL
32209-6808
US

V. Phone/Fax

Practice location:
  • Phone: 904-355-3403
  • Fax: 904-355-4149
Mailing address:
  • Phone: 904-355-3403
  • Fax: 904-355-4149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number7987
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAY1974
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: