Provider Demographics
NPI:1477592301
Name:TIEDEMANN, DAWN (APRN)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:TIEDEMANN
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 1:19 LUNAR DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525
Mailing Address - Country:US
Mailing Address - Phone:203-389-7504
Mailing Address - Fax:203-389-1666
Practice Address - Street 1:455 LEWIS AVENUE
Practice Address - Street 2:SUITE 220
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451
Practice Address - Country:US
Practice Address - Phone:203-238-7747
Practice Address - Fax:203-686-0282
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001916363L00000X, 364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004257433Medicaid
CT004257433Medicaid