Basic Information
Provider Information | |||||||||
NPI: | 1881130870 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LONG | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | DEREE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, AGPCNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3012 N US HIGHWAY 301 | ||||||||
Address2: | SUITE 100 | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336192274 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8134900099 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3012 N US HIGHWAY 301 | ||||||||
Address2: | SUITE 100 | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336192274 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8134900099 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/13/2017 | ||||||||
LastUpdateDate: | 01/19/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0106X | AG0117105 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Occupational Health | 363LA2200X | AG0117105 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163W00000X | 9340365 | FL | N |   | Nursing Service Providers | Registered Nurse |   | 363LP2300X | AG0117105 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LG0600X | AG0117105 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.