Provider Demographics
NPI:1295853547
Name:LONG, DENNIS W (FNP)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:W
Last Name:LONG
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1933
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-1933
Mailing Address - Country:US
Mailing Address - Phone:573-332-7992
Mailing Address - Fax:573-332-7998
Practice Address - Street 1:224 N FREDERICK ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5626
Practice Address - Country:US
Practice Address - Phone:573-332-0121
Practice Address - Fax:573-332-0120
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2013-03-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO096892363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01043Medicare UPIN