Healthcare Provider Details

I. General information

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

Provider Other Name: CANDI NICOLE LONG RN

II. Dates (important events)

Enumeration Date: 10/17/2020
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

691 N NELLIS BLVD
LAS VEGAS NV
89110-5383
US

IV. Provider business mailing address

4454 N. DECATUR BLVD.
LAS VEGAS NV
89130
US

V. Phone/Fax

Practice location:
  • Phone: 702-818-3207
  • Fax:
Mailing address:
  • Phone: 702-507-0983
  • Fax: 702-839-1301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN98099
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number848646
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-CNP835170
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: