Provider Demographics
NPI:1447618947
Name:LONG, MARY ELIZABETH (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:LONG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11164 MAGGIE LN
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-7761
Mailing Address - Country:US
Mailing Address - Phone:618-889-5591
Mailing Address - Fax:
Practice Address - Street 1:11164 MAGGIE LN
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-7761
Practice Address - Country:US
Practice Address - Phone:618-889-5591
Practice Address - Fax:618-216-9993
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.271325163W00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes163W00000XNursing Service ProvidersRegistered Nurse