Basic Information
| Provider Information | |||||||||
| NPI: | 1932413747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | TERRESA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LONG | ||||||||
| OtherFirstName: | TERRESA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 710 SUNSET BLVD N STE A | ||||||||
| Address2: | |||||||||
| City: | SUNSET BEACH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284684340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106632273 | ||||||||
| FaxNumber: | 9106634050 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 SUNSET BLVD N STE A | ||||||||
| Address2: | |||||||||
| City: | SUNSET BEACH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284684340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106632273 | ||||||||
| FaxNumber: | 9106634050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2010 | ||||||||
| LastUpdateDate: | 05/21/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 5004840 | NC | N | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163WP0000X | 5004840 | NC | N | Nursing Service Providers | Registered Nurse | Pain Management | 363LF0000X | 84565 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | XL2218370 | 01 | US DOJ | OTHER | ML2218370 | 01 | US DOJ | OTHER | 84565 | 01 | NC | NCBON RN LICENSE | OTHER | 5004840 | 01 | NC | FNP LIC | OTHER |