Healthcare Provider Details

I. General information

NPI: 1902072036
Provider Name (Legal Business Name): JENNIFER V LONG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12500 WILLOWBROOK RD
CUMBERLAND MD
21502
US

IV. Provider business mailing address

PO BOX 1571 SUITE 307
CUMBERLAND MD
21501-1571
US

V. Phone/Fax

Practice location:
  • Phone: 240-964-3200
  • Fax:
Mailing address:
  • Phone: 301-723-4965
  • Fax: 301-723-4983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR141065
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR141065
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: