=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417254236
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VANESSA ROXANE LONG MSN, APRN-CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2011
-----------------------------------------------------
Last Update Date | 06/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3261 24TH AVE NW STE 101
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73069-6666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-251-7338
-----------------------------------------------------
Fax | 405-444-3965
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14201 W SUNRISE BLVD STE 208
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33323-3207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-251-7338
-----------------------------------------------------
Fax | 405-444-3965
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | ROO89357
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------