Provider Demographics
NPI:1972360998
Name:LONG, NYDIA JEANETTE (LDO)
Entity type:Individual
Prefix:
First Name:NYDIA
Middle Name:JEANETTE
Last Name:LONG
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-3164
Mailing Address - Country:US
Mailing Address - Phone:770-267-1237
Mailing Address - Fax:770-267-3079
Practice Address - Street 1:2050 W SPRING ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-3164
Practice Address - Country:US
Practice Address - Phone:770-267-1237
Practice Address - Fax:770-267-3079
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002683156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician