Provider Demographics
NPI:1821425927
Name:LONGHENRY, NANCY YVETTE (RN)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:YVETTE
Last Name:LONGHENRY
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 1:134 W MADISON AVE
Mailing Address - Street 2:PO BOX 337
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-7022
Mailing Address - Country:US
Mailing Address - Phone:715-463-5004
Mailing Address - Fax:715-463-5003
Practice Address - Street 1:134 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840-7022
Practice Address - Country:US
Practice Address - Phone:715-463-5004
Practice Address - Fax:715-463-5003
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI114823-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100023524Medicaid