Basic Information
| Provider Information | |||||||||
| NPI: | 1477592301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIEDEMANN | ||||||||
| FirstName: | DAWN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 LUNAR DRIVE | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033897504 | ||||||||
| FaxNumber: | 2033891666 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 LEWIS AVENUE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032387747 | ||||||||
| FaxNumber: | 2036860282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 001916 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364SX0200X | 001916 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Oncology |
ID Information
| ID | Type | State | Issuer | Description | 004257433 | 05 | CT | MEDICAID |