Provider Demographics
NPI:1629532080
Name:LONGACRE, DIANA DUDENKOVA (APRN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:DUDENKOVA
Last Name:LONGACRE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10915 BAYMEADOWS RD STE 104
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9131
Mailing Address - Country:US
Mailing Address - Phone:904-683-6924
Mailing Address - Fax:
Practice Address - Street 1:10915 BAYMEADOWS RD STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9131
Practice Address - Country:US
Practice Address - Phone:904-683-6924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000344363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily