MEDICARE: MICHELLE LONG LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN.131919-M-IV	OH

General Provider Information

NPI Number	:	1750735155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE LONG LPN

Provider Business Mailing Address
First Line	:	632 HAMPSHIRE RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45419-4211
Country	:	US
Telephone Number	:	937-241-6123
Fax Number	:

Provider Business Practice Location Address
First Line	:	632 HAMPSHIRE RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45419-4211
Country	:	US
Telephone Number	:	937-241-6123
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2016
Last Update Date	:	04/21/2016

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Directions to “ MICHELLE LONG LPN” Practice Location

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