Provider Demographics
NPI:1639979313
Name:LONG, KYLA JADE (MS)
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:JADE
Last Name:LONG
Suffix:
Gender:
Credentials:MS
Other - Prefix:
Other - First Name:KYLA
Other - Middle Name:JADE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:2620 RIO GRANDE CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-4288
Mailing Address - Country:US
Mailing Address - Phone:757-270-7327
Mailing Address - Fax:
Practice Address - Street 1:2620 RIO GRANDE CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-4288
Practice Address - Country:US
Practice Address - Phone:757-270-7327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86373049133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty