Healthcare Provider Details

I. General information

NPI: 1467723486
Provider Name (Legal Business Name): LONGEVITY MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2012
Last Update Date: 03/11/2021
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 B LYNNFIELD RD STE 205
MEMPHIS TN
38119-5801
US

IV. Provider business mailing address

PO BOX 4355
CORDOVA TN
38088-4355
US

V. Phone/Fax

Practice location:
  • Phone: 901-440-6045
  • Fax: 901-459-3373
Mailing address:
  • Phone: 901-440-6045
  • Fax: 901-459-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License NumberAPN14184
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberAPN14184
License Number StateTN

VIII. Authorized Official

Name: VICKIE D LONG
Title or Position: OWNER
Credential: DNP,FNP-BC,PMHNP-BC
Phone: 901-440-6045