Provider Demographics
NPI:1407031453
Name:LONG, SHAMARA MONIQUE (LVN)
Entity Type:Individual
Prefix:MS
First Name:SHAMARA
Middle Name:MONIQUE
Last Name:LONG
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 W. MOUNTAIN VIEW ST.
Mailing Address - Street 2:
Mailing Address - City:ALTA DENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001
Mailing Address - Country:US
Mailing Address - Phone:517-879-3209
Mailing Address - Fax:
Practice Address - Street 1:760 W. MOUNTAIN VIEW ST.
Practice Address - Street 2:
Practice Address - City:ALTA DENA
Practice Address - State:CA
Practice Address - Zip Code:91001
Practice Address - Country:US
Practice Address - Phone:626-798-6793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 230989164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse