Provider Demographics
NPI:1407181662
Name:LONG, HOLLY J (RN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:J
Last Name:LONG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 OLD KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE KATRINE
Mailing Address - State:NY
Mailing Address - Zip Code:12449-5118
Mailing Address - Country:US
Mailing Address - Phone:845-336-0050
Mailing Address - Fax:
Practice Address - Street 1:96 OLD KINGS HWY
Practice Address - Street 2:
Practice Address - City:LAKE KATRINE
Practice Address - State:NY
Practice Address - Zip Code:12449-5118
Practice Address - Country:US
Practice Address - Phone:845-336-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY435969-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse