Provider Demographics
NPI:1801824693
Name:LONG, REGINA J (CRNP-C, DNP)
Entity Type:Individual
Prefix:DR
First Name:REGINA
Middle Name:J
Last Name:LONG
Suffix:
Gender:F
Credentials:CRNP-C, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 FOREST WALK LN
Mailing Address - Street 2:APT 203
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-2435
Mailing Address - Country:US
Mailing Address - Phone:724-633-0311
Mailing Address - Fax:
Practice Address - Street 1:7955 TUCKERMAN LN
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20854-3243
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:612-659-7101
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR171310363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA038958XRUMedicare PIN
PA038958XRNMedicare PIN