Healthcare Provider Details

I. General information

NPI: 1770004301
Provider Name (Legal Business Name): TARA ANN LONGO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11835 QUEENS BLVD STE 400
FOREST HILLS NY
11375-7211
US

IV. Provider business mailing address

5 JEANNE DR STE 7
NEWBURGH NY
12550-1797
US

V. Phone/Fax

Practice location:
  • Phone: 646-722-7610
  • Fax:
Mailing address:
  • Phone: 845-565-4400
  • Fax: 845-565-4822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number559460734
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: