Healthcare Provider Details

I. General information

NPI: 1447618947
Provider Name (Legal Business Name): MARY ELIZABETH LONG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2016
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11164 MAGGIE LN
MARION IL
62959-7761
US

IV. Provider business mailing address

11164 MAGGIE LN
MARION IL
62959-7761
US

V. Phone/Fax

Practice location:
  • Phone: 618-889-5591
  • Fax: 618-216-9993
Mailing address:
  • Phone: 618-889-5591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.271325
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: