Provider Demographics
NPI:1447918800
Name:LONG, JOHNNA NICCO (FNP)
Entity type:Individual
Prefix:
First Name:JOHNNA
Middle Name:NICCO
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP
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 181
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-0181
Mailing Address - Country:US
Mailing Address - Phone:970-389-7353
Mailing Address - Fax:
Practice Address - Street 1:101 GREENHORN AVE
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631-6040
Practice Address - Country:US
Practice Address - Phone:970-389-7353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0997169-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily