Provider Demographics
NPI:1215244975
Name:LONG, MARDIE ANNE (APRN)
Entity type:Individual
Prefix:MRS
First Name:MARDIE
Middle Name:ANNE
Last Name:LONG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 360
Mailing Address - Street 2:
Mailing Address - City:NEODESHA
Mailing Address - State:KS
Mailing Address - Zip Code:66757-0360
Mailing Address - Country:US
Mailing Address - Phone:620-325-2611
Mailing Address - Fax:620-325-8453
Practice Address - Street 1:1415 N PENN AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-2222
Practice Address - Country:US
Practice Address - Phone:620-331-2400
Practice Address - Fax:620-331-0747
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS75225363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA3003004Medicare PIN