Provider Demographics
NPI:1689450850
Name:LONG, SHEKITA MONIQUE
Entity Type:Individual
Prefix:
First Name:SHEKITA
Middle Name:MONIQUE
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 1:14574 MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-3510
Mailing Address - Country:US
Mailing Address - Phone:313-495-1993
Mailing Address - Fax:
Practice Address - Street 1:14574 MELROSE ST
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-3510
Practice Address - Country:US
Practice Address - Phone:313-495-1993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X, 374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty