Provider Demographics
NPI:1710498746
Name:LONG, DONICA (FNP)
Entity Type:Individual
Prefix:
First Name:DONICA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DONICA
Other - Middle Name:
Other - Last Name:DAVIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:12 E. BRUNSWICK ST
Mailing Address - Street 2:
Mailing Address - City:BYHALIA
Mailing Address - State:MS
Mailing Address - Zip Code:38611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 E. BRUNSWICK ST
Practice Address - Street 2:
Practice Address - City:BYHALIA
Practice Address - State:MS
Practice Address - Zip Code:38611
Practice Address - Country:US
Practice Address - Phone:662-838-2163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902328363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPENDINGMedicaid