Provider Demographics
NPI:1609185859
Name:LONG, ASHLEY (FNP)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:LONG
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:VAUGHN
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:ONE GI CREDENTIALING DEPARTMENT
Mailing Address - Street 2:PO BOX 381468
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-0021
Mailing Address - Country:US
Mailing Address - Phone:662-680-5565
Mailing Address - Fax:662-680-5654
Practice Address - Street 1:589 GARFIELD ST
Practice Address - Street 2:SUITE 201
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6301
Practice Address - Country:US
Practice Address - Phone:662-680-5565
Practice Address - Fax:662-680-5654
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR869971363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02371244Medicaid
302I505099Medicare PIN
MS30250I8979Medicare PIN