Provider Demographics
NPI:1861216384
Name:LONG, EDINAM (DNP)
Entity type:Individual
Prefix:
First Name:EDINAM
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:EDINAM
Other - Middle Name:
Other - Last Name:AMESIMEKU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP
Mailing Address - Street 1:W2261 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-9752
Mailing Address - Country:US
Mailing Address - Phone:574-540-1482
Mailing Address - Fax:
Practice Address - Street 1:1920 LIBAL ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2471
Practice Address - Country:US
Practice Address - Phone:715-732-1648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15580-33207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine