Provider Demographics
NPI:1710603527
Name:LONGMORE, KRISTA BLAU (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:BLAU
Last Name:LONGMORE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:BLAU LONGMORE
Other - Last Name:VAN ROEKEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5860 RANCH LAKE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-3719
Mailing Address - Country:US
Mailing Address - Phone:941-388-8997
Mailing Address - Fax:
Practice Address - Street 1:2020 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4604
Practice Address - Country:US
Practice Address - Phone:941-792-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL660740363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily