Provider Demographics
NPI:1295877033
Name:LONG, MARY LAVONNE (APRN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LAVONNE
Last Name:LONG
Suffix:
Gender:F
Credentials:APRN
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Mailing Address - Street 1:3969 S COBB DR SE STE 206
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6317
Mailing Address - Country:US
Mailing Address - Phone:770-432-5326
Mailing Address - Fax:770-432-5740
Practice Address - Street 1:3969 S COBB DR SE STE 206
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6317
Practice Address - Country:US
Practice Address - Phone:770-432-5326
Practice Address - Fax:770-432-5740
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
GARN077139363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily