Provider Demographics
NPI:1831300888
Name:LONG, THERESA GENETELLI (DNP)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:GENETELLI
Last Name:LONG
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25222 LANKFORD HWY
Mailing Address - Street 2:
Mailing Address - City:CAPE CHARLES
Mailing Address - State:VA
Mailing Address - Zip Code:23310-2000
Mailing Address - Country:US
Mailing Address - Phone:757-331-2818
Mailing Address - Fax:
Practice Address - Street 1:9507 HOSPITAL AVE.
Practice Address - Street 2:
Practice Address - City:NASSAWADOX
Practice Address - State:VA
Practice Address - Zip Code:23413
Practice Address - Country:US
Practice Address - Phone:757-414-8351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAML1442982363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0017138585OtherPRESCRIPTIVE AUTHORITY
VAML1442982OtherLICENSE
VA0017138585OtherPRESCRIPTIVE AUTHORITY