Provider Demographics
NPI:1568623338
Name:LONG, KELLY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:LONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 ROSS ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-2206
Mailing Address - Country:US
Mailing Address - Phone:734-341-7767
Mailing Address - Fax:734-893-3131
Practice Address - Street 1:500 ROSS ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2206
Practice Address - Country:US
Practice Address - Phone:734-341-7767
Practice Address - Fax:734-893-3131
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003518363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601003518OtherMICHIGAN LICENSE
MIMB2577558OtherDEA