Provider Demographics
NPI:1821331984
Name:LONG, BETTY MARIE (FNP, BC)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP, BC
Other - Prefix:
Other - First Name:BETTY
Other - Middle Name:MARIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 OLD SOUTH RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-4120
Mailing Address - Country:US
Mailing Address - Phone:636-224-1000
Mailing Address - Fax:636-246-1008
Practice Address - Street 1:1625 GRATZ BROWN ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-1994
Practice Address - Country:US
Practice Address - Phone:573-603-1460
Practice Address - Fax:573-603-1462
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013028541363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health