Provider Demographics
NPI:1073772349
Name:LONG, MARY LEE (MSN,CRNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:LONG
Suffix:
Gender:F
Credentials:MSN,CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 ROSTRAVER RD
Mailing Address - Street 2:
Mailing Address - City:BELLE VERNON
Mailing Address - State:PA
Mailing Address - Zip Code:15012-9655
Mailing Address - Country:US
Mailing Address - Phone:724-243-0950
Mailing Address - Fax:724-243-0952
Practice Address - Street 1:1645 ROSTRAVER RD
Practice Address - Street 2:
Practice Address - City:BELLE VERNON
Practice Address - State:PA
Practice Address - Zip Code:15012-9655
Practice Address - Country:US
Practice Address - Phone:724-243-0950
Practice Address - Fax:724-243-0952
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007432363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health