=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649354267
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA M LONGO C.N.P.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 07/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9500 E IRONWOOD SQUARE DR
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85258-4582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-948-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 734240
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60673-4240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-460-7890
-----------------------------------------------------
Fax | 708-460-1207
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 279921
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------