Healthcare Provider Details

I. General information

NPI: 1215244975
Provider Name (Legal Business Name): MARDIE ANNE LONG APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 N PENN AVE
INDEPENDENCE KS
67301-2222
US

IV. Provider business mailing address

PO BOX 360
NEODESHA KS
66757-0360
US

V. Phone/Fax

Practice location:
  • Phone: 620-331-2400
  • Fax: 620-331-0747
Mailing address:
  • Phone: 620-325-2611
  • Fax: 620-325-8453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number75225
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: