Provider Demographics
NPI:1730862400
Name:LONG, EDITH
Entity type:Individual
Prefix:
First Name:EDITH
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 1:209 COUNTRY CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-9681
Mailing Address - Country:US
Mailing Address - Phone:740-632-7680
Mailing Address - Fax:
Practice Address - Street 1:209 COUNTRY CLUB BLVD
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-9681
Practice Address - Country:US
Practice Address - Phone:740-632-7680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker