Healthcare Provider Details

I. General information

NPI: 1538139068
Provider Name (Legal Business Name): KATHLEEN ADELE LONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E 8TH ST STE 120
MARIETTA OH
45750-3379
US

IV. Provider business mailing address

PO BOX 449
MARIETTA OH
45750-0449
US

V. Phone/Fax

Practice location:
  • Phone: 740-374-7700
  • Fax: 740-374-7701
Mailing address:
  • Phone: 740-374-4500
  • Fax: 740-374-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNP-04325
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCOA.04325-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: