Basic Information
| Provider Information | |||||||||
| NPI: | 1801918446 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LONGSTREET | ||||||||
| FirstName: | MAUREEN | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 BELLE AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441074202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162272500 | ||||||||
| FaxNumber: | 2162272567 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 BELLE AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441074202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165298683 | ||||||||
| FaxNumber: | 2165297048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 09/03/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | RN260466 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 000000508074 | 01 | OH | ANTHEM BCBS | OTHER | 2727848 | 05 | OH | MEDICAID |