Provider Demographics
NPI:1477591352
Name:LONGAN, ANITA JEAN (RD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:JEAN
Last Name:LONGAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 N IRBY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-2808
Mailing Address - Country:US
Mailing Address - Phone:843-667-9414
Mailing Address - Fax:843-667-1362
Practice Address - Street 1:360 N IRBY ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-2808
Practice Address - Country:US
Practice Address - Phone:843-667-9414
Practice Address - Fax:843-667-1362
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC724655133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ32918Medicare UPIN
SC6245Medicare ID - Type UnspecifiedGROUP NUMBER