Healthcare Provider Details

I. General information

NPI: 1649619768
Provider Name (Legal Business Name): MELISSA J. LONG APN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 SALEM LAKE DR F
LONG GROVE IL
60047-5292
US

IV. Provider business mailing address

22285 N PEPPER RD STE 401
LAKE BARRINGTON IL
60010-2542
US

V. Phone/Fax

Practice location:
  • Phone: 847-719-2220
  • Fax: 847-719-2265
Mailing address:
  • Phone: 847-839-4391
  • Fax: 847-882-6228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209010475
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209010475
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: