MEDICARE: PAULETTE DENISE LONG CRNP

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	363LP0200X	Pediatric Nurse Practitioner	R064853	MD

General Provider Information

NPI Number	:	1689674004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULETTE DENISE LONG CRNP

Provider Business Mailing Address
First Line	:	6005 HEALY FARM RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21228-5362
Country	:	US
Telephone Number	:	410-744-2665
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 DIVISION ST
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21217-3121
Country	:	US
Telephone Number	:	410-383-8300
Fax Number	:	410-728-4412

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	12/22/2010

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