Provider Demographics
NPI:1689674004
Name:LONG, PAULETTE DENISE (CRNP)
Entity Type:Individual
Prefix:
First Name:PAULETTE
Middle Name:DENISE
Last Name:LONG
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 HEALY FARM RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5362
Mailing Address - Country:US
Mailing Address - Phone:410-744-2665
Mailing Address - Fax:
Practice Address - Street 1:1501 DIVISION ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-3121
Practice Address - Country:US
Practice Address - Phone:410-383-8300
Practice Address - Fax:410-728-4412
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR064853363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics