Healthcare Provider Details

I. General information

NPI: 1356933790
Provider Name (Legal Business Name): EMILY R LONG APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EMILY R SISTEK

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 E NORRIS DR STE 2B
OTTAWA IL
61350
US

IV. Provider business mailing address

420 NE GLEN OAK AVE STE 401
PEORIA IL
61603-3112
US

V. Phone/Fax

Practice location:
  • Phone: 309-676-8123
  • Fax: 309-676-8455
Mailing address:
  • Phone: 309-676-8123
  • Fax: 309-676-8455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209021894
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: