Healthcare Provider Details

I. General information

NPI: 1013188663
Provider Name (Legal Business Name): MARY BRONWYN LONG CNS, ACHPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: M BROWNWYN LONG

II. Dates (important events)

Enumeration Date: 03/21/2008
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 JACKSON ST
DENVER CO
80206-2761
US

IV. Provider business mailing address

1400 JACKSON ST
DENVER CO
80206-2761
US

V. Phone/Fax

Practice location:
  • Phone: 303-388-4461
  • Fax: 303-270-2206
Mailing address:
  • Phone: 303-388-4461
  • Fax: 303-398-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number173629
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberR1827185
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: