Healthcare Provider Details

I. General information

NPI: 1750905956
Provider Name (Legal Business Name): GERRI RENEE LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47149 BUSE RD BLDG 1370
PATUXENT RIVER MD
20670-1540
US

IV. Provider business mailing address

26915 HIDDEN ACRES CT
MECHANICSVILLE MD
20659-4305
US

V. Phone/Fax

Practice location:
  • Phone: 301-342-4242
  • Fax:
Mailing address:
  • Phone: 301-848-9898
  • Fax: 240-652-9781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1750905956
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR186212
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR186212
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: