Provider Demographics
NPI:1831113026
Name:LONG, KATHLEEN A (APRN-BC, ND)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:LONG
Suffix:
Gender:F
Credentials:APRN-BC, ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-1948
Mailing Address - Country:US
Mailing Address - Phone:574-307-7673
Mailing Address - Fax:574-307-7692
Practice Address - Street 1:420 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1948
Practice Address - Country:US
Practice Address - Phone:574-307-7673
Practice Address - Fax:574-307-7692
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001562A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200441170Medicaid
IN000000878026OtherBCBS
IN955190TTMedicare ID - Type Unspecified
IN000000878026OtherBCBS
IN200441170Medicaid
P93230Medicare UPIN