Provider Demographics
NPI:1407929870
Name:LONG, KATHY AMANDA (ARNP-BC)
Entity Type:Individual
Prefix:MISS
First Name:KATHY
Middle Name:AMANDA
Last Name:LONG
Suffix:
Gender:F
Credentials:ARNP-BC
Other - Prefix:MISS
Other - First Name:KATHY
Other - Middle Name:AMANDA
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:2831 LONE OAK RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-8041
Mailing Address - Country:US
Mailing Address - Phone:270-554-8373
Mailing Address - Fax:270-554-8987
Practice Address - Street 1:108 AIRWAY DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5841
Practice Address - Country:US
Practice Address - Phone:618-997-7820
Practice Address - Fax:618-997-6721
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3092927363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78905296Medicaid
KY00183002Medicare PIN
KY78905296Medicaid