Provider Demographics
NPI:1962609289
Name:LONG, NICOLE ANN (DO)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 WHITE ST NE
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-2913
Mailing Address - Country:US
Mailing Address - Phone:276-628-4335
Mailing Address - Fax:276-628-3195
Practice Address - Street 1:277 WHITE ST NE
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2913
Practice Address - Country:US
Practice Address - Phone:276-628-4335
Practice Address - Fax:276-628-3195
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017337207V00000X
VA0102202854207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology