Provider Demographics
NPI:1245903830
Name:LONG, TOMARYROEUTH
Entity type:Individual
Prefix:
First Name:TOMARYROEUTH
Middle Name:
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 1:17 STANLEY TER
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01905-2316
Mailing Address - Country:US
Mailing Address - Phone:339-883-8264
Mailing Address - Fax:
Practice Address - Street 1:269 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1314
Practice Address - Country:US
Practice Address - Phone:781-581-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program