Provider Demographics
NPI:1790491694
Name:LONGORIA, LINDA DALE
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:DALE
Last Name:LONGORIA
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 1:496 COPPER DRIVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527
Mailing Address - Country:US
Mailing Address - Phone:408-497-1505
Mailing Address - Fax:
Practice Address - Street 1:496 COPPER DRIVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527
Practice Address - Country:US
Practice Address - Phone:408-497-1505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator