Individual
KELLY LYNN LONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
500 ROSS ST, PLYMOUTH, MI 48170-2206
(734) 341-7767
(734) 893-3131
Mailing address
500 ROSS ST, PLYMOUTH, MI 48170-2206
(734) 341-7767
(734) 893-3131
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
5601003518
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5601003518
MICHIGAN LICENSE
MI
Enumeration date
06/24/2008
Last updated
05/05/2022
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