Healthcare Provider Details

I. General information

NPI: 1154920593
Provider Name (Legal Business Name): CANDI NICOLE LONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CANDI NICOLE LONG NP

II. Dates (important events)

Enumeration Date: 10/17/2020
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10030 W SAHARA AVE
LAS VEGAS NV
89117-6013
US

IV. Provider business mailing address

10030 W SAHARA AVE
LAS VEGAS NV
89117-6013
US

V. Phone/Fax

Practice location:
  • Phone: 702-570-8105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN848646
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: