Provider Demographics
NPI:1740935121
Name:LONG, MCKENZIE M
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:M
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 1:44869 STATE ROUTE 681
Mailing Address - Street 2:
Mailing Address - City:COOLVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45723-9540
Mailing Address - Country:US
Mailing Address - Phone:740-508-1026
Mailing Address - Fax:
Practice Address - Street 1:44869 STATE ROUTE 681
Practice Address - Street 2:
Practice Address - City:COOLVILLE
Practice Address - State:OH
Practice Address - Zip Code:45723-9540
Practice Address - Country:US
Practice Address - Phone:740-508-1026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide