MEDICARE: NICOLE LONG FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	551784	CA

General Provider Information

NPI Number	:	1174634950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LONG FNP

Provider Business Mailing Address
First Line	:	902 CARL RD
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-4807
Country	:	US
Telephone Number	:	510-333-5966
Fax Number	:	925-403-7736

Provider Business Practice Location Address
First Line	:	902 CARL RD
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-4807
Country	:	US
Telephone Number	:	510-333-5966
Fax Number	:	925-403-7736

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	09/17/2012

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