Provider Demographics
NPI:1336949718
Name:LONG, BRANDY ILA MARIE (RN)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:ILA MARIE
Last Name:LONG
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:BRANDY
Other - Middle Name:ILA MARIE
Other - Last Name:JUREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4312 PACIFIC AVE SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1117
Mailing Address - Country:US
Mailing Address - Phone:208-598-0154
Mailing Address - Fax:
Practice Address - Street 1:4312 PACIFIC AVE SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1117
Practice Address - Country:US
Practice Address - Phone:564-669-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-15
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID43561163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency