Provider Demographics
NPI:1629251095
Name:LONGWELL, NICOLE PATRICE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:PATRICE
Last Name:LONGWELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1466 GROVE CIRCLE CT
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-2018
Mailing Address - Country:US
Mailing Address - Phone:727-742-5313
Mailing Address - Fax:727-445-1496
Practice Address - Street 1:1466 GROVE CIRCLE CT
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-2018
Practice Address - Country:US
Practice Address - Phone:727-742-5313
Practice Address - Fax:727-445-1496
Is Sole Proprietor?:No
Enumeration Date:2007-12-08
Last Update Date:2007-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA36728225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist