Provider Demographics
NPI:1861962391
Name:LONG, CHALLIS MADISON (FNP-C)
Entity type:Individual
Prefix:
First Name:CHALLIS
Middle Name:MADISON
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5615 DEAUVILLE STE 240
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79706-2709
Mailing Address - Country:US
Mailing Address - Phone:432-221-5560
Mailing Address - Fax:
Practice Address - Street 1:5615 DEAUVILLE STE 240
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79706-2709
Practice Address - Country:US
Practice Address - Phone:432-221-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP139265OtherSTATE LICENSE