Healthcare Provider Details

I. General information

NPI: 1629219548
Provider Name (Legal Business Name): JENNIFER CRISCO LONG APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 WASHINGTON ST NICU
HARTFORD CT
06106-3322
US

IV. Provider business mailing address

23 BRITTANY RD
GLASTONBURY CT
06033-3055
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-9850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number004058
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: