Provider Demographics
NPI:1841262011
Name:LONGACRE, VANESSA V (APRN)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:V
Last Name:LONGACRE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:1660 PRUDENTIAL DR STE 400
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8188
Practice Address - Country:US
Practice Address - Phone:904-396-0000
Practice Address - Fax:904-390-7500
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005988363LF0000X
IN71000901A363LF0000X
FLAPRN9493697363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200293480Medicaid
IN170270BMedicare ID - Type Unspecified
IN200293480Medicaid