Healthcare Provider Details

I. General information

NPI: 1932529476
Provider Name (Legal Business Name): LINDA LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1929 BUCKLAND AVE
FREMONT OH
43420-3505
US

IV. Provider business mailing address

1929 BUCKLAND AVE
FREMONT OH
43420-3505
US

V. Phone/Fax

Practice location:
  • Phone: 419-332-0091
  • Fax:
Mailing address:
  • Phone: 419-332-0091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN240303
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: