Provider Demographics
NPI:1811371404
Name:LONG, MIKAYLA SUE
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:SUE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKAYLA
Other - Middle Name:SUE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:17432 SMOKEY POINT BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-8784
Mailing Address - Country:US
Mailing Address - Phone:360-653-2222
Mailing Address - Fax:360-653-5730
Practice Address - Street 1:17432 SMOKEY POINT BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-8784
Practice Address - Country:US
Practice Address - Phone:360-653-2222
Practice Address - Fax:360-653-5730
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60560891174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist