Provider Demographics
NPI:1023854106
Name:LONG, KIERSTON JO
Entity type:Individual
Prefix:
First Name:KIERSTON
Middle Name:JO
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 1:442 W WATER ST APT 5
Mailing Address - Street 2:
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-1120
Mailing Address - Country:US
Mailing Address - Phone:570-492-9633
Mailing Address - Fax:
Practice Address - Street 1:442 W WATER ST APT 5
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-1120
Practice Address - Country:US
Practice Address - Phone:570-492-9633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PANONE390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program