Provider Demographics
NPI:1336409770
Name:LONG, ELIZABETH PERRY (IBCLC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:PERRY
Last Name:LONG
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 KEBLE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1405
Mailing Address - Country:US
Mailing Address - Phone:704-517-9710
Mailing Address - Fax:
Practice Address - Street 1:4004 KEBLE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-1405
Practice Address - Country:US
Practice Address - Phone:704-517-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-19
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11152541174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN