Provider Demographics
NPI:1962643494
Name:LONG, PAULA IRENE (COSMET HAIR REPLACEM)
Entity Type:Individual
Prefix:MS
First Name:PAULA
Middle Name:IRENE
Last Name:LONG
Suffix:
Gender:F
Credentials:COSMET HAIR REPLACEM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 SPRUCE LN
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2573
Mailing Address - Country:US
Mailing Address - Phone:304-237-6904
Mailing Address - Fax:
Practice Address - Street 1:407 SPRUCE LN
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2573
Practice Address - Country:US
Practice Address - Phone:304-237-6904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV030306247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other