Healthcare Provider Details

I. General information

NPI: 1730911256
Provider Name (Legal Business Name): KIMLYN LONG MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 08/14/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17561 HILLSIDE AVE SUITE 202
JAMAICA NY
11432-5771
US

IV. Provider business mailing address

17561 HILLSIDE AVE STE 202
JAMAICA NY
11432-5771
US

V. Phone/Fax

Practice location:
  • Phone: 929-279-3399
  • Fax:
Mailing address:
  • Phone: 929-279-3399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KINLYN LONG
Title or Position: OWNER
Credential: MD
Phone: 929-279-3999