Provider Demographics
NPI:1154920593
Name:LONG, CANDI NICOLE
Entity type:Individual
Prefix:
First Name:CANDI
Middle Name:NICOLE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:CANDI
Other - Middle Name:NICOLE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4454 N. DECATUR BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130
Mailing Address - Country:US
Mailing Address - Phone:702-507-0983
Mailing Address - Fax:702-839-1301
Practice Address - Street 1:691 N NELLIS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5383
Practice Address - Country:US
Practice Address - Phone:702-818-3207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-17
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN98099163WP0809X
NV848646207LP2900X
TXAPRN-CNP835170363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine