Provider Demographics
NPI:1750815288
Name:LONG, LATONYA RENEE
Entity type:Individual
Prefix:MRS
First Name:LATONYA
Middle Name:RENEE
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 1:613 WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:HADDON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08107-1219
Mailing Address - Country:US
Mailing Address - Phone:856-240-1095
Mailing Address - Fax:
Practice Address - Street 1:613 WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:HADDON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08107-1219
Practice Address - Country:US
Practice Address - Phone:856-240-1095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ32WG061890001744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management