Provider Demographics
NPI:1841079753
Name:LONG, MARY KATE (FNP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATE
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E WALKER ST STE A
Mailing Address - Street 2:
Mailing Address - City:ORLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95963-2222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 E WALKER ST STE A
Practice Address - Street 2:
Practice Address - City:ORLAND
Practice Address - State:CA
Practice Address - Zip Code:95963-2222
Practice Address - Country:US
Practice Address - Phone:530-865-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95334773163W00000X
CA95030912363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse