Provider Demographics
NPI:1144688656
Name:LONG, CHARLOTTE (NP-C)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36065 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5060
Mailing Address - Country:US
Mailing Address - Phone:254-553-9048
Mailing Address - Fax:
Practice Address - Street 1:3200 W EULESS BLVD
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-6253
Practice Address - Country:US
Practice Address - Phone:817-702-1100
Practice Address - Fax:817-702-6493
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130153363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner