Provider Demographics
NPI:1124182274
Name:LONG, CAROLYN H (CRNP)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:H
Last Name:LONG
Suffix:
Gender:F
Credentials:CRNP
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Mailing Address - Street 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:PPQA MEDICARE COMPLIANCE UNIT 6 WEST KAISER PERMANENTE
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:2100 W PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-3202
Practice Address - Country:US
Practice Address - Phone:202-872-7232
Practice Address - Fax:202-872-7212
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0001078167363L00000X
DCRN41947363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P90119Medicare UPIN
011785M92Medicare ID - Type Unspecified