Provider Demographics
NPI:1508058728
Name:LONG, DEBRA LARAE (FNP-C)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LARAE
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP-C
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 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-996-2173
Mailing Address - Fax:336-996-3254
Practice Address - Street 1:111 GATEWAY CENTER DR
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2999
Practice Address - Country:US
Practice Address - Phone:336-996-2173
Practice Address - Fax:336-996-3254
Is Sole Proprietor?:No
Enumeration Date:2007-08-12
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC091405363LF0000X
NC201305363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily