Provider Demographics
NPI:1821571050
Name:LONG, KIMBERLEE SUSAN (RN)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:SUSAN
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 1:3600 MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1732
Mailing Address - Country:US
Mailing Address - Phone:360-676-6000
Mailing Address - Fax:360-676-6006
Practice Address - Street 1:4104 PUFFIN RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-9579
Practice Address - Country:US
Practice Address - Phone:360-303-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60474538163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse