Provider Demographics
NPI:1629406863
Name:DELONG, KEITH (CNP)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:DELONG
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 SCHROCK RD STE 400
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-1174
Mailing Address - Country:US
Mailing Address - Phone:614-865-4800
Mailing Address - Fax:614-865-4900
Practice Address - Street 1:1033 N HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2409
Practice Address - Country:US
Practice Address - Phone:614-340-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-25
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH15164363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0117025Medicaid