Healthcare Provider Details

I. General information

NPI: 1225734726
Provider Name (Legal Business Name): SYDNEY LYNN LONG CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 S 5TH ST
SAINT CHARLES MO
63301-2913
US

IV. Provider business mailing address

809 COLONY RIDGE CT
FORISTELL MO
63348-1314
US

V. Phone/Fax

Practice location:
  • Phone: 636-922-9182
  • Fax:
Mailing address:
  • Phone: 636-614-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number2018001392
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2023006961
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: