Basic Information
| Provider Information | |||||||||
| NPI: | 1285679274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SULLIVAN | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 601 BENTON AVE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372042303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152929770 | ||||||||
| FaxNumber: | 6153851842 | ||||||||
| Practice Location | |||||||||
| Address1: | 751 NE BLAKELY DR | ||||||||
| Address2: | SUITE 2030 | ||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980296201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253945021 | ||||||||
| FaxNumber: | 4256888110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 10/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN0000077498 | TN | N | Nursing Service Providers | Registered Nurse | 367A00000X | APN0000006273 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | AP60462008 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 3660681 | 05 | TN | MEDICAID | Q015594 | 05 | TN | MEDICAID | 420001234 | 01 | TN | RAILROAD MEDICARE | OTHER |