Provider Demographics
NPI:1598833881
Name:DZIEDZIC, JILL ANN
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:DZIEDZIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11796 SPARKS RD
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:NY
Mailing Address - Zip Code:14065-9715
Mailing Address - Country:US
Mailing Address - Phone:716-864-0250
Mailing Address - Fax:
Practice Address - Street 1:9487 MAIN ST
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:NY
Practice Address - Zip Code:14101-9626
Practice Address - Country:US
Practice Address - Phone:716-864-0250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285626164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse