Basic Information
| Provider Information | |||||||||
| NPI: | 1962405589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | SUZIE | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | C.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 731 PINE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MEDIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190631719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105662485 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5803 KINGSESSING AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191435545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156852684 | ||||||||
| FaxNumber: | 2157264507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP008386 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.