Provider Demographics
NPI:1811660764
Name:MORTENSEN, MERCEDES LONGSHAW (AGNP-C)
Entity type:Individual
Prefix:MRS
First Name:MERCEDES
Middle Name:LONGSHAW
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:MRS
Other - First Name:MERCEDES
Other - Middle Name:LONGSHAW
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3204 S HARMONY CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2706
Mailing Address - Country:US
Mailing Address - Phone:925-262-7059
Mailing Address - Fax:
Practice Address - Street 1:522 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1905
Practice Address - Country:US
Practice Address - Phone:801-485-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT283800-4405363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology