Provider Demographics
NPI:1992453823
Name:LONG, NICHOLE (RN)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 1338
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:81423-1338
Mailing Address - Country:US
Mailing Address - Phone:970-640-8896
Mailing Address - Fax:
Practice Address - Street 1:1010 S RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4831
Practice Address - Country:US
Practice Address - Phone:970-787-2074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO190041163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse