Healthcare Provider Details

I. General information

NPI: 1558545780
Provider Name (Legal Business Name): BETH R LONG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4022 LIBERTY ST
MILAN TN
38358-3453
US

IV. Provider business mailing address

4022 LIBERTY ST
MILAN TN
38358
US

V. Phone/Fax

Practice location:
  • Phone: 731-686-7004
  • Fax: 731-686-7078
Mailing address:
  • Phone: 731-686-7004
  • Fax: 731-686-7078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13077
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: