Provider Demographics
NPI:1710766902
Name:LONG, COURTNEY BROOKE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BROOKE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 STATE AVE STE 303
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4590
Mailing Address - Country:US
Mailing Address - Phone:850-872-3939
Mailing Address - Fax:
Practice Address - Street 1:2202 STATE AVE STE 303
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4590
Practice Address - Country:US
Practice Address - Phone:850-872-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11027864363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner