Healthcare Provider Details

I. General information

NPI: 1861436321
Provider Name (Legal Business Name): DENNIS LONG NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 CHADWICK DR
JACKSON MS
39204-3404
US

IV. Provider business mailing address

PO BOX 75473
BALTIMORE MD
21275-5473
US

V. Phone/Fax

Practice location:
  • Phone: 904-805-1300
  • Fax: 904-805-1302
Mailing address:
  • Phone: 904-805-1300
  • Fax: 904-805-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR851248
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: