Provider Demographics
NPI:1386386043
Name:LONGCHAMP, ALBERT-MARY
Entity type:Individual
Prefix:MR
First Name:ALBERT-MARY
Middle Name:
Last Name:LONGCHAMP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 DATELAND RD SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6681
Mailing Address - Country:US
Mailing Address - Phone:954-547-9618
Mailing Address - Fax:
Practice Address - Street 1:14502 N DALE MABRY HWY STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2040
Practice Address - Country:US
Practice Address - Phone:800-640-3451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11018757163W00000X, 363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health