Provider Demographics
NPI:1285011361
Name:JEANNIE DILWORTH, LLC
Entity Type:Organization
Organization Name:JEANNIE DILWORTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:860-432-7771
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-28
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001987363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008058819Medicaid