Provider Demographics
NPI:1083780290
Name:LONG, KRYSTAL MATSUE (BA, LC)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:MATSUE
Last Name:LONG
Suffix:
Gender:F
Credentials:BA, LC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1196 GOLD DUST TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-4520
Mailing Address - Country:US
Mailing Address - Phone:530-414-1348
Mailing Address - Fax:
Practice Address - Street 1:2034 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6499
Practice Address - Country:US
Practice Address - Phone:530-541-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA41912OtherSANTA CLARA COUNTY ID