Provider Demographics
NPI:1750115515
Name:LONG, MAKENNA RAE
Entity type:Individual
Prefix:
First Name:MAKENNA
Middle Name:RAE
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 1:6801 S YOSEMITE ST
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-1406
Mailing Address - Country:US
Mailing Address - Phone:303-773-9000
Mailing Address - Fax:
Practice Address - Street 1:6801 S YOSEMITE ST
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-1406
Practice Address - Country:US
Practice Address - Phone:303-773-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.1000010-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily