Healthcare Provider Details

I. General information

NPI: 1710766902
Provider Name (Legal Business Name): COURTNEY BROOKE LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 W BALDWIN RD STE C
PANAMA CITY FL
32405-3359
US

IV. Provider business mailing address

625 W BALDWIN RD STE C
PANAMA CITY FL
32405-3359
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-0329
  • Fax:
Mailing address:
  • Phone: 850-769-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11027864
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: