Healthcare Provider Details

I. General information

NPI: 1114463049
Provider Name (Legal Business Name): DYMOND LONG APN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 E 95TH ST
CHICAGO IL
60617
US

IV. Provider business mailing address

PO BOX 746715
ATLANTA GA
30374-6715
US

V. Phone/Fax

Practice location:
  • Phone: 773-768-4437
  • Fax: 773-564-3515
Mailing address:
  • Phone: 773-352-1515
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209015381
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277001290
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: