Provider Demographics
NPI:1235355306
Name:LONGBALLA, MYRIAM DANIELA (CST-FA)
Entity Type:Individual
Prefix:
First Name:MYRIAM
Middle Name:DANIELA
Last Name:LONGBALLA
Suffix:
Gender:F
Credentials:CST-FA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 SUNRIDGE CT E
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-5743
Mailing Address - Country:US
Mailing Address - Phone:775-849-1331
Mailing Address - Fax:
Practice Address - Street 1:40 SUNRIDGE CT E
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-5743
Practice Address - Country:US
Practice Address - Phone:775-849-1331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO064336246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist