Provider Demographics
NPI:1720649676
Name:LONG, KELLY (LVN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3325
Mailing Address - Country:US
Mailing Address - Phone:909-865-2336
Mailing Address - Fax:909-629-5294
Practice Address - Street 1:2180 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3325
Practice Address - Country:US
Practice Address - Phone:909-865-2336
Practice Address - Fax:909-629-5294
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN204910164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse