Provider Demographics
NPI:1851577217
Name:LONG, CYNTHIA DANNA
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:DANNA
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 1:116 LIZZIE LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-9747
Mailing Address - Country:US
Mailing Address - Phone:601-951-4974
Mailing Address - Fax:
Practice Address - Street 1:116 LIZZIE LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-9747
Practice Address - Country:US
Practice Address - Phone:601-951-4974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA2092174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist