Provider Demographics
NPI:1184171886
Name:LONGSHORE, EMMIE NORRELL
Entity type:Individual
Prefix:
First Name:EMMIE
Middle Name:NORRELL
Last Name:LONGSHORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 GORDON ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110-1519
Mailing Address - Country:US
Mailing Address - Phone:770-537-1234
Mailing Address - Fax:770-537-1237
Practice Address - Street 1:21178 MAIN STREET
Practice Address - Street 2:
Practice Address - City:RANBURNE
Practice Address - State:AL
Practice Address - Zip Code:36273
Practice Address - Country:US
Practice Address - Phone:938-526-0010
Practice Address - Fax:938-526-0011
Is Sole Proprietor?:No
Enumeration Date:2016-09-10
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN233967363LF0000X
AL1-196334363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1861915647OtherGROUP NPI