Provider Demographics
NPI:1619589223
Name:LONG, BRENNA JEAN (NP-C)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:JEAN
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 1:13404 RED LEAF CT
Mailing Address - Street 2:
Mailing Address - City:NUNICA
Mailing Address - State:MI
Mailing Address - Zip Code:49448-9325
Mailing Address - Country:US
Mailing Address - Phone:616-644-9454
Mailing Address - Fax:
Practice Address - Street 1:2201 S GETTY ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1207
Practice Address - Country:US
Practice Address - Phone:231-733-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704282784363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner