Healthcare Provider Details

I. General information

NPI: 1134605918
Provider Name (Legal Business Name): MRS. DIELKA IFILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 07/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 ABBOTT TER
WATERBURY CT
06702-1431
US

IV. Provider business mailing address

44 ABBOTT TER
WATERBURY CT
06702-1431
US

V. Phone/Fax

Practice location:
  • Phone: 203-755-4870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7654
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: