Healthcare Provider Details

I. General information

NPI: 1720498686
Provider Name (Legal Business Name): KASHITI GENIKKA NICOLE LONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2436 N SHARON AMITY RD STE 102
CHARLOTTE NC
28205-8401
US

IV. Provider business mailing address

2436 N SHARON AMITY RD STE 102
CHARLOTTE NC
28205-8401
US

V. Phone/Fax

Practice location:
  • Phone: 980-272-0061
  • Fax: 980-245-3637
Mailing address:
  • Phone: 980-272-0061
  • Fax: 980-245-3637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40704
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2024-02587
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: