Provider Demographics
NPI:1619222510
Name:DZIEDZIC, CHERYL ANN (BA)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:ANN
Last Name:DZIEDZIC
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 CROSSWAY E
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-1204
Mailing Address - Country:US
Mailing Address - Phone:631-218-4949
Mailing Address - Fax:631-567-3640
Practice Address - Street 1:45 CROSSWAY E
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-1204
Practice Address - Country:US
Practice Address - Phone:631-218-4949
Practice Address - Fax:631-567-3640
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY936593174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist