Provider Demographics
NPI:1689052821
Name:LONG, KAITLYN
Entity Type:Individual
Prefix:
First Name:KAITLYN
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 1:15210 L P BAILEY MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:NATHALIE
Mailing Address - State:VA
Mailing Address - Zip Code:24577-3304
Mailing Address - Country:US
Mailing Address - Phone:434-349-3113
Mailing Address - Fax:434-349-2172
Practice Address - Street 1:15210 L P BAILEY MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:NATHALIE
Practice Address - State:VA
Practice Address - Zip Code:24577-3304
Practice Address - Country:US
Practice Address - Phone:434-349-3113
Practice Address - Fax:434-349-2172
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172460363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner