Provider Demographics
NPI:1639532609
Name:LONG, ANGELA L (FNP)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:618-235-3687
Mailing Address - Fax:618-239-9492
Practice Address - Street 1:19 WOLF CREEK DR
Practice Address - Street 2:DEPT OTOLARYNGOLOGY
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2355
Practice Address - Country:US
Practice Address - Phone:618-235-3687
Practice Address - Fax:618-239-9492
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013742363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420078251Medicaid