Healthcare Provider Details

I. General information

NPI: 1598833881
Provider Name (Legal Business Name): JILL ANN DZIEDZIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9487 MAIN ST
MACHIAS NY
14101-9626
US

IV. Provider business mailing address

11796 SPARKS RD
FREEDOM NY
14065-9715
US

V. Phone/Fax

Practice location:
  • Phone: 716-864-0250
  • Fax:
Mailing address:
  • Phone: 716-864-0250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number285626
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: