Healthcare Provider Details

I. General information

NPI: 1619222510
Provider Name (Legal Business Name): CHERYL ANN DZIEDZIC B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 CROSSWAY E
BOHEMIA NY
11716-1204
US

IV. Provider business mailing address

45 CROSSWAY E
BOHEMIA NY
11716-1204
US

V. Phone/Fax

Practice location:
  • Phone: 631-218-4949
  • Fax: 631-567-3640
Mailing address:
  • Phone: 631-218-4949
  • Fax: 631-567-3640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number936593
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: