Provider Demographics
NPI:1396120523
Name:LONG, MINDY J (NP)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:J
Last Name:LONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:J
Other - Last Name:SHUTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:8111 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-865-5146
Practice Address - Fax:317-865-5148
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28182964A363LN0000X
IN71005631A363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201331210Medicaid