Provider Demographics
NPI:1558900183
Name:LONG, KATHRYN (NP-C)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 MEDICAL PARK DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3607
Mailing Address - Country:US
Mailing Address - Phone:616-942-9610
Mailing Address - Fax:
Practice Address - Street 1:1055 MEDICAL PARK DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3607
Practice Address - Country:US
Practice Address - Phone:616-942-9610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704253154363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care