Healthcare Provider Details

I. General information

NPI: 1205387297
Provider Name (Legal Business Name): COURTNEY LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S 5TH AVE
WEST READING PA
19611-2143
US

IV. Provider business mailing address

PO BOX 13579
READING PA
19612-3579
US

V. Phone/Fax

Practice location:
  • Phone: 484-628-5455
  • Fax:
Mailing address:
  • Phone: 484-628-0799
  • Fax: 484-334-7026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberSP016904
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN578356
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: