Healthcare Provider Details

I. General information

NPI: 1962851337
Provider Name (Legal Business Name): BARBRA LONG GRADUS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 MADRONE ST
WILLITS CA
95490-4249
US

IV. Provider business mailing address

84 MADRONE ST
WILLITS CA
95490-4249
US

V. Phone/Fax

Practice location:
  • Phone: 707-456-3062
  • Fax: 707-456-3063
Mailing address:
  • Phone: 707-456-3062
  • Fax: 707-456-3063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95016871
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF340298-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: