Provider Demographics
NPI:1194156695
Name:LONG, JUDY
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JUDY
Other - Middle Name:
Other - Last Name:NUTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IBCLC
Mailing Address - Street 1:301 OLD SAN FRANCISCO RD
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-6386
Mailing Address - Country:US
Mailing Address - Phone:408-523-3681
Mailing Address - Fax:
Practice Address - Street 1:301 OLD SAN FRANCISCO RD
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94086-6386
Practice Address - Country:US
Practice Address - Phone:408-523-3681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-25465174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN