Provider Demographics
NPI:1497255160
Name:LONG, BRANDY MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:MICHELLE
Last Name:LONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 678402
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8402
Mailing Address - Country:US
Mailing Address - Phone:334-712-9999
Mailing Address - Fax:334-702-2119
Practice Address - Street 1:1736 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3040
Practice Address - Country:US
Practice Address - Phone:334-712-9999
Practice Address - Fax:334-702-2119
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-104421363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner