Healthcare Provider Details

I. General information

NPI: 1194090159
Provider Name (Legal Business Name): CHARLOTTE LONG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8815 182ND ST
JAMAICA NY
11423-1733
US

IV. Provider business mailing address

8815 182ND ST
JAMAICA NY
11423-1733
US

V. Phone/Fax

Practice location:
  • Phone: 718-297-9821
  • Fax: 718-658-5288
Mailing address:
  • Phone: 718-297-9821
  • Fax: 718-658-5288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number22 493249
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: