Provider Demographics
NPI:1386629988
Name:DZIWANOWSKI, JENNIFER S (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:DZIWANOWSKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12248
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28561-2248
Mailing Address - Country:US
Mailing Address - Phone:252-514-6685
Mailing Address - Fax:252-514-2745
Practice Address - Street 1:702 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5238
Practice Address - Country:US
Practice Address - Phone:252-633-5333
Practice Address - Fax:252-633-9443
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201496363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH128BMedicare PIN
P72390Medicare UPIN
NCH128AMedicare PIN