Provider Demographics
NPI:1396906533
Name:LONGFORS, NANCY SUE (MD)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:SUE
Last Name:LONGFORS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 GLENN MITCHELL DR STE 512
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-0179
Mailing Address - Country:US
Mailing Address - Phone:757-507-8850
Mailing Address - Fax:
Practice Address - Street 1:2075 GLENN MITCHELL DR STE 512
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-0179
Practice Address - Country:US
Practice Address - Phone:757-507-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58621208600000X
WI65696-20208600000X
NDPT17488208600000X
ND17488208600000X
VA0101254169208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1396906533Medicaid
WI1396906533Medicaid