Provider Demographics
NPI:1467701672
Name:LONG, MARY ANN (CPNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:CHESNUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1825 MARTHA BERRY BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1625
Mailing Address - Country:US
Mailing Address - Phone:706-295-5331
Mailing Address - Fax:
Practice Address - Street 1:1013 N 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2664
Practice Address - Country:US
Practice Address - Phone:706-234-9992
Practice Address - Fax:706-234-9026
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN175517363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner