Provider Demographics
NPI:1821401043
Name:LONG, LISA MICHELLE (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:LONG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 506
Mailing Address - Street 2:
Mailing Address - City:PARK HILLS
Mailing Address - State:MO
Mailing Address - Zip Code:63601-0506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:512 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PARK HILLS
Practice Address - State:MO
Practice Address - Zip Code:63601-2624
Practice Address - Country:US
Practice Address - Phone:573-431-3341
Practice Address - Fax:573-431-6580
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013024129163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse