Provider Demographics
NPI:1700585122
Name:LONG, SARA-GRACE KATHERINE
Entity Type:Individual
Prefix:
First Name:SARA-GRACE
Middle Name:KATHERINE
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 1:2078 STANDING ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-7908
Mailing Address - Country:US
Mailing Address - Phone:901-848-2202
Mailing Address - Fax:
Practice Address - Street 1:2100 EXETER RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3966
Practice Address - Country:US
Practice Address - Phone:901-701-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
174671OtherBAPTIST