MEDICARE: MRS. AMANDA ANN LONG MSN, RN, CPNP-PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	247320	NC
2	363LP0200X	Pediatric Nurse Practitioner	20172101	NC

General Provider Information

NPI Number	:	1306358650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA ANN LONG MSN, RN, CPNP-PC

Provider Business Mailing Address
First Line	:	285 W DORA ST
Second Line	:
City	:	ANGIER
State	:	NC
Zip	:	27501-9542
Country	:	US
Telephone Number	:	919-639-9995
Fax Number	:

Provider Business Practice Location Address
First Line	:	285 W DORA ST
Second Line	:
City	:	ANGIER
State	:	NC
Zip	:	27501-9542
Country	:	US
Telephone Number	:	919-639-9995
Fax Number	:	919-639-3518

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2017
Last Update Date	:	10/26/2017

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