Provider Demographics
NPI:1487278628
Name:LONG, MARCIA MARIE
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:MARIE
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 1:454 GEORGETOWN SHORTCUT RD
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32112-4504
Mailing Address - Country:US
Mailing Address - Phone:386-467-2095
Mailing Address - Fax:
Practice Address - Street 1:454 GEORGETOWN SHORTCUT RD
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-4504
Practice Address - Country:US
Practice Address - Phone:386-467-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty