Healthcare Provider Details

I. General information

NPI: 1790137651
Provider Name (Legal Business Name): KIMM CHRISTINE LONG ACCNS-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2016
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N MORLEY ST STE A120
MOBERLY MO
65270-3685
US

IV. Provider business mailing address

1600 N MORLEY ST
MOBERLY MO
65270-3666
US

V. Phone/Fax

Practice location:
  • Phone: 660-372-9595
  • Fax: 660-372-9696
Mailing address:
  • Phone: 660-372-9595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number153901
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number2016022480
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number2016022480
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number2016022480
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: