Provider Demographics
NPI:1508453697
Name:LONG, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LONG
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 1:373 NEW QUARTERS RD
Mailing Address - Street 2:
Mailing Address - City:MEADOWBROOK
Mailing Address - State:WV
Mailing Address - Zip Code:26404-7217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:373 NEW QUARTERS RD
Practice Address - Street 2:
Practice Address - City:MEADOWBROOK
Practice Address - State:WV
Practice Address - Zip Code:26404-7217
Practice Address - Country:US
Practice Address - Phone:304-844-7256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant