MEDICARE: CRYSTAL LYNN LONG FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F09171083	OH

General Provider Information

NPI Number	:	1306355912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL LYNN LONG FNP-C

Provider Business Mailing Address
First Line	:	81 TOWNSHIP ROAD 1373
Second Line	:
City	:	SOUTH POINT
State	:	OH
Zip	:	45680-7395
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	81 TOWNSHIP ROAD 1373
Second Line	:
City	:	SOUTH POINT
State	:	OH
Zip	:	45680-7395
Country	:	US
Telephone Number	:	304-972-4145
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2017
Last Update Date	:	07/09/2020

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