Provider Demographics
NPI:1275887051
Name:LONGORIA, KATHERINE MARIE (PNP, RN)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:MARIE
Last Name:LONGORIA
Suffix:
Gender:F
Credentials:PNP, RN
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:MARIE
Other - Last Name:HARIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP, RN
Mailing Address - Street 1:2680 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4828
Mailing Address - Country:US
Mailing Address - Phone:269-324-2400
Mailing Address - Fax:269-324-0450
Practice Address - Street 1:2680 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4828
Practice Address - Country:US
Practice Address - Phone:269-324-2400
Practice Address - Fax:269-324-0450
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704250766163WP0200X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1275887051Medicaid
MI1801818752OtherBCBSM - BMG
MIM97850018 - BMGMedicare PIN