Provider Demographics
NPI:1548656598
Name:LONGEVITY HEALTH AND WELLNESS
Entity type:Organization
Organization Name:LONGEVITY HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:ALMERICO
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:985-373-3126
Mailing Address - Street 1:848 E BOSTON ST
Mailing Address - Street 2:UNIT 501
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-2982
Mailing Address - Country:US
Mailing Address - Phone:985-373-3126
Mailing Address - Fax:225-341-5388
Practice Address - Street 1:1101 VILLAGE WALK
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4006
Practice Address - Country:US
Practice Address - Phone:985-373-3126
Practice Address - Fax:225-341-5388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05758363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1558502237Medicare NSC