Basic Information
| Provider Information | |||||||||
| NPI: | 1508058728 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | LARAE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369962173 | ||||||||
| FaxNumber: | 3369963254 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 GATEWAY CENTER DR | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272842999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369962173 | ||||||||
| FaxNumber: | 3369963254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2007 | ||||||||
| LastUpdateDate: | 07/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 091405 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 201305 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.