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General NPI Number Information
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NPI Number | 1306259916
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Entity Type | Individual
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Provider Name | SHANNON ROSE LONG D.O.
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Gender | Female
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Dates
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Enumeration Date | 06/11/2014
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Last Update Date | 12/30/2023
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Provider Practice Location Address
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Address Line | 325 FOLLY RD STE 102A
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City | CHARLESTON
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State | SC
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Zip | 29412-2507
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Country | US
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Telephone | 843-762-1440
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 751649
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City | CHARLOTTE
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State | NC
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Zip | 28275-1649
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Country | US
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Telephone | 843-789-1620
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 36707
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License Number State | SC
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