Provider Demographics
NPI:1790345726
Name:LONG, GILLIAN K (FNP-C)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:K
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
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Mailing Address - Street 1:660 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8512
Mailing Address - Country:US
Mailing Address - Phone:314-448-3791
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:1 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5068
Practice Address - Country:US
Practice Address - Phone:618-463-8500
Practice Address - Fax:618-433-6792
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209018721363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner