Provider Demographics
NPI:1649689415
Name:DIZNEY, ASHLEY
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:DIZNEY
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 1:26 BITTERSWEET LN
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-1919
Mailing Address - Country:US
Mailing Address - Phone:203-314-0179
Mailing Address - Fax:
Practice Address - Street 1:520 SAYBROOK RD STE 105
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4700
Practice Address - Country:US
Practice Address - Phone:203-314-0179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5810363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health