Provider Demographics
NPI:1548941107
Name:LONG, IVANA SHALONDA
Entity type:Individual
Prefix:
First Name:IVANA
Middle Name:SHALONDA
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IVANA
Other - Middle Name:SHALONDA
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:890 W FARIS RD STE 470
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4281
Practice Address - Country:US
Practice Address - Phone:864-455-1600
Practice Address - Fax:864-455-3095
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC240441163W00000X
SC27775363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse