Healthcare Provider Details

I. General information

NPI: 1477592301
Provider Name (Legal Business Name): DAWN TIEDEMANN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 LEWIS AVENUE SUITE 220
MERIDEN CT
06451
US

IV. Provider business mailing address

19 LUNAR DRIVE
WOODBRIDGE CT
06525
US

V. Phone/Fax

Practice location:
  • Phone: 203-238-7747
  • Fax: 203-686-0282
Mailing address:
  • Phone: 203-389-7504
  • Fax: 203-389-1666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number001916
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code364SX0200X
TaxonomyOncology Clinical Nurse Specialist
License Number001916
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: