Provider Demographics
NPI:1851020903
Name:DWYER, KILLEEN
Entity Type:Individual
Prefix:
First Name:KILLEEN
Middle Name:
Last Name:DWYER
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 1:16 MCGRATH LN
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:CT
Mailing Address - Zip Code:06249-2606
Mailing Address - Country:US
Mailing Address - Phone:860-884-9074
Mailing Address - Fax:
Practice Address - Street 1:16 MCGRATH LN
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:CT
Practice Address - Zip Code:06249-2606
Practice Address - Country:US
Practice Address - Phone:860-884-9074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT93660163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT93660OtherLICENSE