Provider Demographics
NPI:1275860108
Name:LONGO, NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LONGO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 BETHLEHEM PIKE
Mailing Address - Street 2:PO BOX 6
Mailing Address - City:FLOURTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19031-1500
Mailing Address - Country:US
Mailing Address - Phone:267-210-7435
Mailing Address - Fax:
Practice Address - Street 1:1818 BETHLEHEM PIKE # 6
Practice Address - Street 2:
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031-1500
Practice Address - Country:US
Practice Address - Phone:267-210-7435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-13
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014972207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine