Provider Demographics
NPI:1184100067
Name:LONG, NICOLE MARIE (APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:BRICKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:64 MAIN ST FL 2
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-3701
Mailing Address - Country:US
Mailing Address - Phone:603-283-1570
Mailing Address - Fax:603-352-9648
Practice Address - Street 1:40 AVON ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-3516
Practice Address - Country:US
Practice Address - Phone:603-357-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH085982-23363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3137907Medicaid