Provider Demographics
NPI:1013188663
Name:LONG, MARY BRONWYN (CNS, ACHPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BRONWYN
Last Name:LONG
Suffix:
Gender:F
Credentials:CNS, ACHPN
Other - Prefix:
Other - First Name:M
Other - Middle Name:BROWNWYN
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1400 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-2761
Mailing Address - Country:US
Mailing Address - Phone:303-388-4461
Mailing Address - Fax:303-398-1211
Practice Address - Street 1:1400 JACKSON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-2761
Practice Address - Country:US
Practice Address - Phone:303-388-4461
Practice Address - Fax:303-270-2206
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO173629364SA2200X
MNR1827185364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65976754Medicaid
COCOA101095Medicare PIN