Provider Demographics
NPI:1144792342
Name:LONGO, KELLY MICHELLE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:LONGO
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 1:227 BLUE POINT RD W
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-2222
Mailing Address - Country:US
Mailing Address - Phone:516-382-3480
Mailing Address - Fax:
Practice Address - Street 1:227 BLUE POINT RD W
Practice Address - Street 2:
Practice Address - City:HOLTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11742-2222
Practice Address - Country:US
Practice Address - Phone:516-382-3480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2653605174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist