Healthcare Provider Details

I. General information

NPI: 1356370985
Provider Name (Legal Business Name): BEVERLY JEAN LONG CRNA, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 E ELM ST
REPUBLIC MO
65738-1500
US

IV. Provider business mailing address

678 E ELM ST
REPUBLIC MO
65738-1500
US

V. Phone/Fax

Practice location:
  • Phone: 417-732-6894
  • Fax:
Mailing address:
  • Phone: 417-732-6894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number122344
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024166617
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number51993
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number172980 (APN 4715)
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: