Healthcare Provider Details

I. General information

NPI: 1548577885
Provider Name (Legal Business Name): TERESA KAY LONG RN, BSN, COHN-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 REPLACEMENT AVE SUITE 139
FORT LEONARD WOOD MO
65473-9089
US

IV. Provider business mailing address

126 MISSOURI AVE OCCUPATIONAL HEALTH BOX 1227
FORT LEONARD WOOD MO
65473-8952
US

V. Phone/Fax

Practice location:
  • Phone: 573-329-1933
  • Fax: 573-329-8521
Mailing address:
  • Phone: 573-329-1993
  • Fax: 573-329-8521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number103766
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: