Provider Demographics
NPI:1174634950
Name:LONG, NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 CARL RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4807
Mailing Address - Country:US
Mailing Address - Phone:510-333-5966
Mailing Address - Fax:925-403-7736
Practice Address - Street 1:902 CARL RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4807
Practice Address - Country:US
Practice Address - Phone:510-333-5966
Practice Address - Fax:925-403-7736
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA551784363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily