Healthcare Provider Details

I. General information

NPI: 1275127540
Provider Name (Legal Business Name): KAYLA LYNNE LONG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2021
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11012 E 13 MILE RD STE 112
WARREN MI
48093-2546
US

IV. Provider business mailing address

4466 W BRISTOL RD
FLINT MI
48507-3170
US

V. Phone/Fax

Practice location:
  • Phone: 586-582-0760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010456
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: