Provider Demographics
NPI:1538965389
Name:LONG, MARITA MICHELLE
Entity type:Individual
Prefix:MRS
First Name:MARITA
Middle Name:MICHELLE
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 1:8113 REYNOLDSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-9328
Mailing Address - Country:US
Mailing Address - Phone:614-463-0543
Mailing Address - Fax:
Practice Address - Street 1:8113 REYNOLDSWOOD DR
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-9328
Practice Address - Country:US
Practice Address - Phone:614-463-0543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty