Provider Demographics
NPI:1770203218
Name:LONG, LILLIE MARIE
Entity type:Individual
Prefix:
First Name:LILLIE
Middle Name:MARIE
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 1:18305 N. SCOTTSDALE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254
Mailing Address - Country:US
Mailing Address - Phone:480-235-9639
Mailing Address - Fax:
Practice Address - Street 1:18305 N. SCOTTSDALE RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254
Practice Address - Country:US
Practice Address - Phone:480-235-9639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider