Provider Demographics
NPI:1093019234
Name:DZIEDZIC, KATIE LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:DZIEDZIC
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LYNN
Other - Last Name:BACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:P.O. BOX 415933
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5933
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR STREET
Practice Address - Street 2:HARTFORD HOSPITAL CARDIOLOGY DEPT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-5037
Practice Address - Country:US
Practice Address - Phone:860-545-4398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004533363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004045332Medicaid
CT004045332Medicaid
CTD400050173 - C00023Medicare PIN