Basic Information
| Provider Information | |||||||||
| NPI: | 1023691334 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 E SOUTH ST STE 308 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908054598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626303111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3300 E SOUTH ST STE 308 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908054598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626303111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2021 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95015362 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 95015362 | 01 | CA | NP LICENSE | OTHER |