Provider Demographics
NPI:1689349078
Name:LONG, CAROLYN DIANE
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:DIANE
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 1:834 E 320 N
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-5535
Mailing Address - Country:US
Mailing Address - Phone:801-358-9166
Mailing Address - Fax:
Practice Address - Street 1:834 E 320 N
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-5535
Practice Address - Country:US
Practice Address - Phone:801-358-9166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT167634594OtherDRIVERS LICENSE