Provider Demographics
NPI:1750482683
Name:LONG, NICOLE L (DC)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18729 88TH AVE., E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375
Mailing Address - Country:US
Mailing Address - Phone:253-262-1408
Mailing Address - Fax:
Practice Address - Street 1:4902 TACOMA MALL BLVD
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7149
Practice Address - Country:US
Practice Address - Phone:253-473-0300
Practice Address - Fax:253-473-0305
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00033851111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB33811Medicare PIN