Provider Demographics
NPI:1043505688
Name:LONG, CHERYL DENISE (LPN)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:DENISE
Last Name:LONG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3646 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-2303
Mailing Address - Country:US
Mailing Address - Phone:414-364-6791
Mailing Address - Fax:
Practice Address - Street 1:3646 N 15TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-2303
Practice Address - Country:US
Practice Address - Phone:414-364-6791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-11
Last Update Date:2011-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30928931164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse