Provider Demographics
NPI:1902195902
Name:LONG, CONNIE SUE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:SUE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 LANTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-3854
Mailing Address - Country:US
Mailing Address - Phone:417-256-2570
Mailing Address - Fax:417-256-6497
Practice Address - Street 1:1015 LANTON RD
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-3854
Practice Address - Country:US
Practice Address - Phone:417-256-2570
Practice Address - Fax:417-256-6497
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator