Provider Demographics
NPI:1619015047
Name:CARLL-LONG, SALLY ANN (NP)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:ANN
Last Name:CARLL-LONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 TURNPIKE RD
Mailing Address - Street 2:UNIT 6
Mailing Address - City:NEW IPSWICH
Mailing Address - State:NH
Mailing Address - Zip Code:03071-3030
Mailing Address - Country:US
Mailing Address - Phone:603-878-0965
Mailing Address - Fax:
Practice Address - Street 1:326 NICHOLS RD
Practice Address - Street 2:SUITE 26
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-1914
Practice Address - Country:US
Practice Address - Phone:978-345-6272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA169432363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health