=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649491184
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANA RENEE LONGMEYER FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 08/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5800 GODFREY RD
-----------------------------------------------------
City | GODFREY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62035-2426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-468-4431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4339 PINE RD
-----------------------------------------------------
City | PALMYRA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62674-6673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-468-4431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209003307
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------