Provider Demographics
NPI:1548735988
Name:LONGEVILLE, ANGELA M (NP)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:M
Last Name:LONGEVILLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:925 WEST ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2757
Practice Address - Country:US
Practice Address - Phone:815-223-3300
Practice Address - Fax:815-223-3394
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018462363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily