Provider Demographics
NPI:1083495501
Name:LONG, MELINDA RENEE
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:RENEE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6433 TIDE WATER DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-4938
Mailing Address - Country:US
Mailing Address - Phone:314-368-4302
Mailing Address - Fax:
Practice Address - Street 1:6433 TIDE WATER DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-4938
Practice Address - Country:US
Practice Address - Phone:314-368-4302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health