Provider Demographics
NPI:1750861985
Name:LONG, LAUREN (NP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 SHUTTLE CT APT 105
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-8128
Mailing Address - Country:US
Mailing Address - Phone:256-599-9603
Mailing Address - Fax:
Practice Address - Street 1:4311 NORFOLK PKWY STE 114
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-8617
Practice Address - Country:US
Practice Address - Phone:321-339-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9470265363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner