Provider Demographics
NPI:1801918446
Name:LONGSTREET, MAUREEN (CNM)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:LONGSTREET
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 BELLE AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4202
Mailing Address - Country:US
Mailing Address - Phone:216-227-2500
Mailing Address - Fax:216-227-2567
Practice Address - Street 1:1450 BELLE AVE STE 300
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4202
Practice Address - Country:US
Practice Address - Phone:216-529-8683
Practice Address - Fax:216-529-7048
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN260466367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000508074OtherANTHEM BCBS
OH2727848Medicaid
OH2727848Medicaid