Provider Demographics
NPI:1558429944
Name:STIELAU, JEAN B (APRN)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:B
Last Name:STIELAU
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:HARTFORD HEALTHCARE MEDICAL GROUP
Mailing Address - Street 2:85 SEYMOUR ST, SUITE 409
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106
Mailing Address - Country:US
Mailing Address - Phone:860-547-0616
Mailing Address - Fax:
Practice Address - Street 1:85 SEYMOUR ST STE 409
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5523
Practice Address - Country:US
Practice Address - Phone:860-547-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001607363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004016077Medicaid
CTD400002845 - C00814Medicare PIN
CTP72925Medicare UPIN