Healthcare Provider Details

I. General information

NPI: 1841079753
Provider Name (Legal Business Name): MARY KATE LONG FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2023
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E WALKER ST STE A
ORLAND CA
95963-2222
US

IV. Provider business mailing address

750 E WALKER ST STE A
ORLAND CA
95963-2222
US

V. Phone/Fax

Practice location:
  • Phone: 530-865-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95030912
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95334773
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: