Healthcare Provider Details

I. General information

NPI: 1760395792
Provider Name (Legal Business Name): PENNY LEE LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 VETERANS DR STE 103
ELKHORN NE
68022-7047
US

IV. Provider business mailing address

1021 E MILITARY AVE
FREMONT NE
68025-5263
US

V. Phone/Fax

Practice location:
  • Phone: 402-932-6996
  • Fax: 531-484-2547
Mailing address:
  • Phone: 402-932-6996
  • Fax: 531-484-2547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: