Provider Demographics
NPI:1538139068
Name:LONG, KATHLEEN ADELE (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ADELE
Last Name:LONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:300 E 8TH ST STE 120
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3379
Practice Address - Country:US
Practice Address - Phone:740-374-7700
Practice Address - Fax:740-374-7701
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-04325363LG0600X
OHCOA.04325-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810029099Medicaid
OH0132593Medicaid
OH0132593Medicaid