Provider Demographics
NPI:1427758945
Name:LONG, TIFFANY DAWN
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DAWN
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:704 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:MARLINTON
Mailing Address - State:WV
Mailing Address - Zip Code:24954-1142
Mailing Address - Country:US
Mailing Address - Phone:304-799-6865
Mailing Address - Fax:
Practice Address - Street 1:704 3RD AVE
Practice Address - Street 2:
Practice Address - City:MARLINTON
Practice Address - State:WV
Practice Address - Zip Code:24954-1142
Practice Address - Country:US
Practice Address - Phone:304-799-6865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV40763164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse