Provider Demographics
NPI:1801072020
Name:LONG, LISA LAVONN (RN CNS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LAVONN
Last Name:LONG
Suffix:
Gender:F
Credentials:RN CNS
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Other - First Name:
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Mailing Address - Street 1:DIVISION OF VASCULAR SURGERY, MMC 195
Mailing Address - Street 2:420 DELAWARE STREET SE MMC 195
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-4893
Mailing Address - Fax:
Practice Address - Street 1:2800 CAMPUS DR
Practice Address - Street 2:SUITE 30
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2645
Practice Address - Country:US
Practice Address - Phone:763-398-2203
Practice Address - Fax:763-398-2233
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2018-06-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MNR1414190364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health