Provider Demographics
NPI:1043686280
Name:LONG, KATHRYN ANN (RN, LAC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:RN, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 319
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-0319
Mailing Address - Country:US
Mailing Address - Phone:763-310-4704
Mailing Address - Fax:
Practice Address - Street 1:12760 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045-9342
Practice Address - Country:US
Practice Address - Phone:763-310-4704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR170102-3163W00000X
MN1972171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No163W00000XNursing Service ProvidersRegistered Nurse