Provider Demographics
NPI:1346542735
Name:LONGBRAKE, LONA MARIE (RN)
Entity Type:Individual
Prefix:MS
First Name:LONA
Middle Name:MARIE
Last Name:LONGBRAKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:LONA
Other - Middle Name:MARIE
Other - Last Name:WISHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:HWY 34 & 47
Mailing Address - Street 2:FORT THOMPSON INDIAN HEALTH SERVICE
Mailing Address - City:FORT THOMPSON
Mailing Address - State:SD
Mailing Address - Zip Code:57339-0200
Mailing Address - Country:US
Mailing Address - Phone:605-245-1500
Mailing Address - Fax:605-245-2384
Practice Address - Street 1:HWY 34 & 37
Practice Address - Street 2:
Practice Address - City:FORT THOMPSON
Practice Address - State:SD
Practice Address - Zip Code:57339-0200
Practice Address - Country:US
Practice Address - Phone:605-245-1500
Practice Address - Fax:605-245-2384
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR033717163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5549010Medicaid
SD5549010Medicaid