Healthcare Provider Details

I. General information

NPI: 1356091888
Provider Name (Legal Business Name): KIMBERLY ANN LONGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2022
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 E ANTIETAM ST
HAGERSTOWN MD
21740-5754
US

IV. Provider business mailing address

324 E ANTIETAM ST
HAGERSTOWN MD
21740-5754
US

V. Phone/Fax

Practice location:
  • Phone: 240-362-7128
  • Fax: 240-362-7731
Mailing address:
  • Phone: 240-362-7128
  • Fax: 240-362-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR169573
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: