Healthcare Provider Details

I. General information

NPI: 1033285242
Provider Name (Legal Business Name): CAROL LYDIA WIEDIGER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL LYDIA WIEDIGER AISTON

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 ELECTRIC AVE
PORT HURON MI
48060-8127
US

IV. Provider business mailing address

500 VINE STREET HUMAN RESOURCES
HARTFORD CT
06112
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-8900
  • Fax:
Mailing address:
  • Phone: 860-297-0905
  • Fax: 860-297-0914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704367059
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number403445
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number000886
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202201526NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: