Provider Demographics
NPI:1679086953
Name:LONG, KEAUNDRA LATRECEA
Entity Type:Individual
Prefix:
First Name:KEAUNDRA
Middle Name:LATRECEA
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 1:13501 HOOPER RD TRLR 176
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77047-5078
Mailing Address - Country:US
Mailing Address - Phone:281-747-9530
Mailing Address - Fax:
Practice Address - Street 1:13501 HOOPER RD TRLR 176
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77047-5078
Practice Address - Country:US
Practice Address - Phone:281-747-9530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA0008271107374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide