Provider Demographics
NPI:1033285242
Name:WIEDIGER, CAROL LYDIA (APRN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LYDIA
Last Name:WIEDIGER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:LYDIA
Other - Last Name:WIEDIGER AISTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 VINE STREET
Mailing Address - Street 2:HUMAN RESOURCES
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112
Mailing Address - Country:US
Mailing Address - Phone:860-297-0905
Mailing Address - Fax:860-297-0914
Practice Address - Street 1:3111 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8127
Practice Address - Country:US
Practice Address - Phone:810-985-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704367059363LP0808X
NY403445363LP0808X
CT000886364S00000X
OR202201526NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS36160Medicare UPIN