Provider Demographics
NPI:1275062598
Name:MDLONGWA, MEMORY
Entity Type:Individual
Prefix:
First Name:MEMORY
Middle Name:
Last Name:MDLONGWA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 UPPER CHESAPEAKE DR
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4324
Mailing Address - Country:US
Mailing Address - Phone:443-643-1000
Mailing Address - Fax:
Practice Address - Street 1:1681 BRICE CT
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1610
Practice Address - Country:US
Practice Address - Phone:317-698-0405
Practice Address - Fax:317-698-0405
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR225465367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered