Provider Demographics
NPI:1346803509
Name:LONG, FELICIA NICOLE
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:NICOLE
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 1:15497 DONNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-1678
Mailing Address - Country:US
Mailing Address - Phone:704-606-2966
Mailing Address - Fax:
Practice Address - Street 1:221 E EXMORE ST STE D
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1808
Practice Address - Country:US
Practice Address - Phone:704-606-2966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist