Provider Demographics
NPI:1104094937
Name:LONG, LINDA MARIE (FNP-BC)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73236
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-0107
Mailing Address - Country:US
Mailing Address - Phone:949-528-4758
Mailing Address - Fax:949-288-0432
Practice Address - Street 1:187 AVENIDA LA PATA
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6307
Practice Address - Country:US
Practice Address - Phone:949-528-4758
Practice Address - Fax:949-288-0432
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000750363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA131622OtherMEDICARE IDENTIFICATION NUMBER (PTAN)