Provider Demographics
NPI:1649204298
Name:LONG, SANDRA KAY (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:KAY
Last Name:LONG
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 PINEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5469
Mailing Address - Country:US
Mailing Address - Phone:618-549-6756
Mailing Address - Fax:
Practice Address - Street 1:VETERANS AFFAIRS MEDICAL CENTER
Practice Address - Street 2:2401 WEST MAIN
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist