Provider Demographics
NPI:1043589112
Name:LONG, GENEVIEVE (LVN)
Entity type:Individual
Prefix:MS
First Name:GENEVIEVE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 MEADOWVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-3012
Mailing Address - Country:US
Mailing Address - Phone:817-321-4938
Mailing Address - Fax:
Practice Address - Street 1:1101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4802
Practice Address - Country:US
Practice Address - Phone:817-321-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103600164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse