Healthcare Provider Details

I. General information

NPI: 1427341163
Provider Name (Legal Business Name): JAMILEI MICHELLE ALWORDEN LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#6 SALLISAW VIEW DR
SALLISAW OK
74955
US

IV. Provider business mailing address

#6 SALLISAW VIEW DR
SALLISAW OK
74955
US

V. Phone/Fax

Practice location:
  • Phone: 940-447-7912
  • Fax:
Mailing address:
  • Phone: 940-447-7912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: