Provider Demographics
NPI:1316588650
Name:LONG, CYNTHIA ANN
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
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 1:10487 COUNTY ROAD 4 LOT 100
Mailing Address - Street 2:
Mailing Address - City:SWANTON
Mailing Address - State:OH
Mailing Address - Zip Code:43558-9247
Mailing Address - Country:US
Mailing Address - Phone:419-901-3320
Mailing Address - Fax:
Practice Address - Street 1:10487 COUNTY ROAD 4 LOT 100
Practice Address - Street 2:
Practice Address - City:SWANTON
Practice Address - State:OH
Practice Address - Zip Code:43558-9247
Practice Address - Country:US
Practice Address - Phone:419-901-3320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver