Provider Demographics
NPI:1073112553
Name:LONG, JONDRA DIANNE (MS, BSN, RN)
Entity Type:Individual
Prefix:
First Name:JONDRA
Middle Name:DIANNE
Last Name:LONG
Suffix:
Gender:F
Credentials:MS, BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8105 TIMBERTREE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-1605
Mailing Address - Country:US
Mailing Address - Phone:937-776-2685
Mailing Address - Fax:
Practice Address - Street 1:3800 VICTORY PKWY UNIT 1
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45207-1092
Practice Address - Country:US
Practice Address - Phone:513-745-3802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH254692163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse