Healthcare Provider Details

I. General information

NPI: 1609185859
Provider Name (Legal Business Name): ASHLEY LONG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY VAUGHN LONG FNP

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

589 GARFIELD ST SUITE 201
TUPELO MS
38801-6301
US

IV. Provider business mailing address

ONE GI CREDENTIALING DEPARTMENT PO BOX 381468
GERMANTOWN TN
38183-0021
US

V. Phone/Fax

Practice location:
  • Phone: 662-680-5565
  • Fax: 662-680-5654
Mailing address:
  • Phone: 662-680-5565
  • Fax: 662-680-5654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR869971
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: