MEDICARE: CANDI NICOLE LONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse	RN98099	NV
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	848646	NV
3	363LF0000X	Family Nurse Practitioner	APRN-CNP835170	TX

General Provider Information

NPI Number	:	1154920593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDI NICOLE LONG

Provider Business Mailing Address
First Line	:	4454 N. DECATUR BLVD.
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130
Country	:	US
Telephone Number	:	702-507-0983
Fax Number	:	702-839-1301

Provider Business Practice Location Address
First Line	:	691 N NELLIS BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-5383
Country	:	US
Telephone Number	:	702-818-3207
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2020
Last Update Date	:	08/25/2023

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Directions to “ CANDI NICOLE LONG ” Practice Location

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