Provider Demographics
NPI:1962157925
Name:LONG, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
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:PO BOX 1266
Mailing Address - Street 2:
Mailing Address - City:CRAB ORCHARD
Mailing Address - State:WV
Mailing Address - Zip Code:25827-1266
Mailing Address - Country:US
Mailing Address - Phone:304-207-7338
Mailing Address - Fax:
Practice Address - Street 1:117 EXCESS CT
Practice Address - Street 2:
Practice Address - City:CRAB ORCHARD
Practice Address - State:WV
Practice Address - Zip Code:25827
Practice Address - Country:US
Practice Address - Phone:304-207-7338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant