Provider Demographics
NPI:1609524776
Name:LONG, MARY (APRN CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:APRN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 NW 39TH EXPY
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-2513
Mailing Address - Country:US
Mailing Address - Phone:405-789-6711
Mailing Address - Fax:
Practice Address - Street 1:6800 NW 39TH EXPY
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-2513
Practice Address - Country:US
Practice Address - Phone:405-789-6711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207060363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK207060OtherOKLAHOMA BOARD OF NURSING