Provider Demographics
NPI:1265487425
Name:DILWORTH, JEANNIE (APRN)
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:
Last Name:DILWORTH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 SULLIVAN AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2025
Mailing Address - Country:US
Mailing Address - Phone:860-432-7771
Mailing Address - Fax:860-432-7774
Practice Address - Street 1:925 SULLIVAN AVE
Practice Address - Street 2:UNIT 2
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2025
Practice Address - Country:US
Practice Address - Phone:860-432-7771
Practice Address - Fax:860-432-7774
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001987363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004253407Medicaid
CT004253407Medicaid