Provider Demographics
NPI:1558873984
Name:WIEZALIS, EMILY MARTON (APRN)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:MARTON
Last Name:WIEZALIS
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 1:312 GEORGETOWN DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2357
Mailing Address - Country:US
Mailing Address - Phone:860-729-2545
Mailing Address - Fax:
Practice Address - Street 1:2288 BERLIN TURNPIKE
Practice Address - Street 2:2288 BERLIN TURNPIKE
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111
Practice Address - Country:US
Practice Address - Phone:860-757-3575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7323363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily