Provider Demographics
NPI:1790137651
Name:LONG, KIMM CHRISTINE (ACCNS-AG)
Entity Type:Individual
Prefix:
First Name:KIMM
Middle Name:CHRISTINE
Last Name:LONG
Suffix:
Gender:F
Credentials:ACCNS-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N MORLEY ST
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-3666
Mailing Address - Country:US
Mailing Address - Phone:660-372-9595
Mailing Address - Fax:
Practice Address - Street 1:1600 N MORLEY ST STE A120
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-3685
Practice Address - Country:US
Practice Address - Phone:660-372-9595
Practice Address - Fax:660-372-9696
Is Sole Proprietor?:No
Enumeration Date:2016-07-04
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO153901163WC0200X
MO2016022480364SA2100X, 364SG0600X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1790137651Medicaid