Provider Demographics
NPI:1881130870
Name:LONG, LAURA DEREE (MS, AGPCNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:DEREE
Last Name:LONG
Suffix:
Gender:F
Credentials:MS, AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 N US HIGHWAY 301
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-2274
Mailing Address - Country:US
Mailing Address - Phone:813-490-0099
Mailing Address - Fax:
Practice Address - Street 1:3012 N US HIGHWAY 301
Practice Address - Street 2:SUITE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-2274
Practice Address - Country:US
Practice Address - Phone:813-490-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9340365163W00000X
FLAG01171052083P0011X, 363LA2200X, 363LG0600X, 363LP2300X, 363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
No163W00000XNursing Service ProvidersRegistered Nurse
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care