Provider Demographics
NPI:1851521660
Name:LONG, NICOLE C (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:C
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:320 CENTRAL CITY PLZ
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-6441
Mailing Address - Country:US
Mailing Address - Phone:724-335-5721
Mailing Address - Fax:724-335-5778
Practice Address - Street 1:320 CENTRAL CITY PLZ
Practice Address - Street 2:
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068-6441
Practice Address - Country:US
Practice Address - Phone:724-335-5721
Practice Address - Fax:724-335-5778
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002241152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025773000001Medicaid