Provider Demographics
NPI:1619651296
Name:LONGMIRE, WENDOLYN RACQUEL (RN BSN)
Entity Type:Individual
Prefix:
First Name:WENDOLYN
Middle Name:RACQUEL
Last Name:LONGMIRE
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 FULLER ROAD ANN ARBOR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2300
Mailing Address - Country:US
Mailing Address - Phone:734-546-2016
Mailing Address - Fax:
Practice Address - Street 1:2215 FULLER ROAD ANN ARBOR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2300
Practice Address - Country:US
Practice Address - Phone:734-546-2016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704319872163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult